Modified Rankin Score (mRS) (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:

Modified Rankin Score (mRS)

Collected For:

CSTK-02, CSTK-10

Definition:

Documentation in the medical record of a Modified Rankin Score (mRS). The Modified Rankin Score (mRS) is a 6 point disability scale with possible scores ranging from 0 to 5. A separate category of 6 is usually added for patients who expire. The Modified Rankin Score (mRS) is the most widely used outcome measure in stroke clinical trials. Standardized interviews to obtain a mRS score are recommended at 3 months (90 days) following hospital discharge.

Question:

What is the patient's Modified Rankin Score (mRS) at 90 days post-discharge?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

0 The patient has no residual symptoms.

1 The patient has no significant disability; able to carry out all pre-stroke activities.

2 The patient has slight disability; unable to carry out all pre-stroke activities but able to look after self without daily help.

3 The patient has moderate disability; requiring some external help but able to walk without the assistance of another individual.

4 The patient has moderately severe disability; unable to walk or attend to bodily functions without assistance of another individual.

5 The patient has severe disability; bedridden, incontinent, requires continuous care.

6 The patient has expired (during the hospital stay or after discharge from the hospital).

7 Unable to contact patient/caregiver.

8 Modified Rankin Score not performed, OR unable to determine (UTD) from the medical record documentation.

Notes for Abstraction:

Modified Rankin Score (mRS) may be documented by the physician/APN/PA, nurse (RN), medical assistant, or any individual trained to perform the mRS.
No value should be recorded more than once.
If value 8 (UTD) is selected, no other values should be selected.
Select the value (values 0-6) corresponding to the mRS documented at 90 days post-discharge.
If more than one value is documented at 90 days, select the highest value.
If a score range is documented, e.g. 2-3, select the higher value.
If no mRS is documented, select “UTD”.
Documentation of a mRS obtained within the 90 day timeframe (i.e., 75 to 105 days after hospital discharge) via telephone or in-person is acceptable.
If the patient cannot be interviewed because of communication deficits or other limitations, an interview with the patient's caregiver is acceptable.
If documentation reflects that after 3 attempts to contact the patient and/or caregiver, the mRS could not be obtained because attempts to contact the patient and/or caregiver were unsuccessful, select allowable value “7”.
EXAMPLES:
- Home phone number provided at discharge is a wrong number, AND no e-mail address or other contact information was provided by the patient and/or caregiver at discharge.
- Calls placed go to a voicemail system. Message left for patient and/or caregiver requesting a return phone call, but no return call received.
- Calls placed within the 90 day timeframe. Message left for patient and/or caregiver. Call returned after 105 days.
If documentation reflects that the mRS could not be obtained due to a language barrier with the patient and/or caregiver, and no hospital or patient translator was available to interpret, select allowable value “7”.
If the patient and/or caregiver refuse to be interviewed, select allowable value “7”.
If documentation reflects that the mRS could not be obtained because the patient is a resident of a nursing home or extended/immediate care facility, and the facility refuses to provide patient information due to HIPPA regulations or other reasons, select allowable value "7".
The caregiver is defined as the patient's family or other person (e.g. home health, VNA provider, prison official or law enforcement personnel) who will be responsible for care of the patient after discharge.

Suggested Data Sources:

History and physical
Progress notes
Care Transition Record
Consultation form
Home health forms
Logs from follow-up phone calls or other logs that record follow-up information
Outpatient record

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
None	Unchecked checkbox next to a mRS (e.g., blank checkbox on a pre-printed form next to mRS). Pre-printed Modified Rankin Score Form (mRS) left blank.

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

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