Specifications Manual for Joint Commission National Quality Measures (v2023B)
Posted: 02/03/2023
Home » Care Transition Record-Follow-Up Treatment(s) and Service(s) Needed

Release Notes:
Data Element
Version 2023B

Name:Care Transition Record-Follow-Up Treatment(s) and Service(s) Needed
Collected For: ACHF-03
Definition:Documentation in the care transition record includes follow-up treatment(s) and service(s) needed. Follow-up treatments and services include treatments and services to be initiated or continued to manage the patient's heart failure after discharge from the hospital.
Question:Is there documentation in the medical record of the care transition record which includes follow-up treatment and services needed?
Allowable Values:

Y (Yes) There is documentation that the care transition record included follow-up treatment and services.

N (No) There is no documentation that the care transition record included follow-up treatment or services, OR unable to determine from medical record documentation.

Notes for Abstraction:
  • Follow-up treatments and services needed after hospital discharge should be documented in the care transition record. The list of treatments and services includes, but is not limited to: laboratory tests and results; imaging services (e.g., MRI, PET/CT, ultrasound, x-rays and other radiology services); rehabilitation services (e.g., PT, OT, SLT); respiratory treatments (e.g., oxygen therapy, CPAP BiPAP, nebulizer treatments); nutrition services; hospice or home care services; mental health, or other counseling services. Durable medical equipment needs and transportation needs (e.g., Medi-car) should be included.
  • Documentation of one or more follow-up treatments and/or sevices in the care transition record, select YES'.
  • If medical record documentation indicates that no follow-up treatment or services were ordered, select YES'.
  • Unchecked checkbox or blank space for documentation of follow-up treatment or services, select NO'.
Suggested Data Sources:
  • Aftercare discharge plan
  • Care transition record
  • Continuing care plan
  • Discharge plan
  • Discharge summary
  • Medication reconciliation form
  • Physician orders
  • Progress notes
  • Referral form
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Care Transition Record-Follow-Up Treatment(s) and Service(s) Needed
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Specifications Manual for Joint Commission National Quality Measures (v2023B)
Discharges 07-01-23 (3Q23) through 12-31-23 (4Q23)


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