Release Notes:
Data Element
Version 2010A1
| Data Element Name: | Comfort Measures Only-Stroke |
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| Collected For: | , STK-10, , , , , , , , , , All Records-Stroke |
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| Definition: | Physician/nurse practitioner/physician assistant documentation the patient was receiving comfort measures only. Commonly referred to as “palliative care” in the medical community and “comfort care” by the general public. Palliative care includes attention to the psychological and spiritual needs of the patient and support for the dying patient and the patient’s family. Usual interventions are not received because a medical decision was made to limit care to comfort measures only. Comfort Measures Only are not equivalent to the following: Do Not Resuscitate (DNR), living will, no code, no heroic measure. |
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| Suggested Data Collection Question: | Is there physician/nurse practitioner/physician assistance documentation the patient was receiving comfort measures only? |
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| Format: | | Length: | |
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| Type: | Alphanumeric |
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| Occurs: | |
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| Allowable Values: |
Y (Yes) There is physician/nurse practitioner/physician assistant documentation that the patient was receiving comfort measures anytime during the hospital stay.
N (No) There is no documentation the patient as receiving comfort measures only or unable to determine from medical record documentation
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| Notes for Abstraction: |
- If the only mention of comfort measures or hospice is at discharge, select “No” for the answer.
- If DNR-CC is documented, select “No” unless there is documented clarification that CC stands for “comfort care”
- If any of the inclusions are documented select “Yes” regardless of other documentation.
- If “continue supportive care” is documented in the context of a patient’s age, chronic illness or terminal/grave prognosis, select “Yes”.
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| Suggested Data Sources: |
PHYSICIAN/NURSE PRACTITIONER/PHYSICIAN ASSISTANT DOCUMENTATION ONLY
- Admitting physician orders
- Consultation notes
- Emergency Department record
- History and physical
- Physician admitting note
- Physician orders
- Progress notes
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
- Comfort measures only
- Comfort measures provided
- Hospice care
- Maintain treatment for comfort, terminal care
- Palliative care
- Physician documentation that care is limited at family’s request due to patient’s age or chronic illness or patient’s conditions is grave or that death is imminent
- Supportive care only
- V66.7 encounter for palliative care
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- Chemical code only
- DNR
- Do not cardiovert
- Do not defibrillate
- Do not intubate (DNI)
- Living will
- NCR
- No antiarrhythmic therapy
- No artificial respirations
- No cardiac monitoring
- No chest compressions
- No code
- No code 99
- No heroic or aggressive measures
- No intubation and/or ventilation
- No invasive procedures
- No other protocols associated with advanced cardiac life support
- No resuscitative medication
- No resuscitative measures (NRM)
- No vasopressors
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Comfort Measures Only-Stroke
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
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