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Release Notes:
Data Element
Version 2010A1

Data Element Name: Discharge Instructions Address Symptoms Worsening
Collected For: HF-1,
Definition:Written discharge instructions or other documentation of educational material given to patient/caregiver addressing what to do if heart failure symptoms worsen after discharge.
Suggested Data Collection Question:Did the WRITTEN discharge instructions or other documentation of educational material given to the patient/caregiver address what to do if heart failure symptoms worsen after discharge?

Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y     (Yes)   WRITTEN discharge instructions/educational material given to patient/caregiver address what to do if heart failure symptoms worsen after discharge.

N   (No)   WRITTEN discharge instructions/educational material do not address symptoms worsening or unable to determine from medical record documentation.

JOINT COMMISSION NOTE TO PROGRAMMERS:
In order to identify the specific discharge instructions that are missing, the internal variables (discharge counter and missing flag) must be stored so calculations of rates for each instruction component can be performed.

Notes for Abstraction:
  • Include instructions/educational material which address what to do if heart failure symptoms recur or do not improve after discharge.
  • If written instructions address what to do if symptoms worsen, problems occur, the patient's condition changes or worsens, etc., without being specified or described as heart failure in nature – (e.g., “Call physician/advanced practice nurse/physician assistant (physician/APN/PA) if symptoms get worse,” “Contact office with any problems”), infer they are referring to heart failure symptoms, unless documentation suggests otherwise.
  • Some hospitals use discharge instruction sheets, brochures, booklets, and teaching sheets to provide written instructions to the patient. Others use electronically formatted media such as videos, CDs, and DVDs, which are also acceptable educational materials.
    • Documentation must clearly convey that the patient was given a copy of the discharge instruction material to take home. When a discharge instruction sheet, teaching sheet, brochure, or booklet is present in the medical record and there is no documentation which clearly suggests that a copy was given to the patient/caregiver (e.g., statement on form such as “pink copy to patient”), the inference should be made that it was given IF the patient's name or the medical record number appears on the material AND hospital staff or the patient/caregiver has signed the material.
    • When a copy of the material is not included in the medical record, documentation must clearly convey that instructions which address what to do if heart failure symptoms worsen are included in the material. Use only the documentation provided in the medical record itself. If material is located outside of the medical record, it should not be reviewed and used in abstraction.
    • Documentation of instructions in the educational material which address what to do if heart failure symptoms worsen can take many forms.
      -Examples:
      -Discharge nursing note which outlines the areas covered in the material such as "Heart Failure Management brochure given to pt. - addresses diet, activity, and worsening symptoms"
      -Notation on discharge instruction sheet such as "Worsening signs or symptoms to report to physician/APN/PA: Given Heart Failure Management CD"
  • Written instructions do NOT need to be given at the time of discharge. Instructions given anytime during the hospital stay are acceptable.
  • If the patient refused written discharge instructions or other documentation of educational material which addressed worsening heart failure symptoms, select “Yes.”
  • In cases where a document provides a checkbox for this information and the checkbox is left unchecked, credit for giving written instructions to the patient/caregiver which address worsening heart failure symptoms should not be taken. E.g., Checkbox on discharge instruction sheet which reads, “Notify your doctor if you experience difficulty breathing, weight gain of 5 lbs. or more, or swelling in your feet” is left unchecked – select “No.”
  • The caregiver is defined as the patient’s family or any other person (e.g., home health/VNA provider) who will be responsible for care of the patient after discharge.
Suggested Data Sources:
  • Discharge summary
  • Care plans/clinical pathways
  • Discharge instruction sheet
  • Discharge progress notes
  • Home health referral form
  • Nursing discharge notes
  • Teaching sheet
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Heart failure symptoms
  • Ankle/foot/leg edema
  • Ankle/foot/leg swelling
  • Breathing difficulty
  • Decreased exercise tolerance
  • Edema (location not specified)
  • Fatigue
  • Shortness of breath (SOB) or other breathing difficulty, in any context
  • Swelling (location not specified)
  • Weight gain

Worsening symptoms (examples)

  • “Call the office if weight gain greater than 2 pounds.”
  • “Come to the emergency room if you experience a problem with breathing.”
  • “Make an appointment if your foot swelling doesn't subside.”
  • “Take additional diuretic if your weight gain continues.”
  • “Call physician/APN/PA if symptoms recur.”

  • Instructions on heart failure symptoms without mention of what to do if symptoms worsen
  • Instructions on what to do with worsening symptoms noted only as Not Applicable (N/A), None, or left blank

Discharge Instructions Address Symptoms Worsening
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)