Release Notes:
Data Element
Version 2010B
| Data Element Name: | Assessed for Rehabilitation Services |
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| Collected For: | STK-10, |
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| Definition: | There is documentation in the record that the patient was assessed for or received rehabilitation services. |
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| Suggested Data Collection Question: | Was the patient assessed for and/or did the patient receive rehabilitation services? |
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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, patient was assessed for or received rehabilitation services)
N (No, patient was not assessed for or received rehabilitation services, OR unable to determine from medical record documentation) |
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| Notes for Abstraction: | Documentation in the medical record must address rehabilitation services. Examples of this may include items noted in the Guidelines for Abstraction below. |
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| Suggested Data Sources: |
- Progress notes
- Physician orders
- Consultant reports
- Referral forms
- Rehabilitation records
- Clinical logs
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
- Consult by rehabilitation services
- Assessment/treatment by members of the rehabilitation team
- Patient received rehabilitation services during hospitalization
- Patient transferred to rehabilitation facility
- Patient referred to rehabilitation services following discharge
- Specific documentation that patient was assessed and reasons patient ineligible to receive rehabilitation services (e.g., symptoms resolved, patient returned to prior level of function, poor prognosis, patient unable to tolerate rehabilitation therapeutic regimen)
- Patient/family refused rehabilitation services
Examples of members of a rehabilitation team may include but are not limited to:
- Physiatrist
- Neuro-psychologist
- Physical therapist
- Occupational therapist
- Speech and language pathologist
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- Request for consultation for rehabilitation services that was not performed
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Assessed for Rehabilitation Services
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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