When we’re reviewing your clinicians’ data, it may be helpful to know what we are looking for in order for us to verify to CMS that your data is accurate and complete. Measure 154 requires documentation that patients aged 65 and older with a history of falls have had a fall risk assessment completed within 12 months.
This documentation may be found in the patient’s medical record. The relevant document should be made available to the auditor for the patient requested.
What kind of documentation are you looking for?
AAOE has chosen to adopt the Centers for Disease Control and Preventions recommendations from the STEADI Initiative. The process for this may be found in the Resources tab of Empower under AAOE Registry Resources. We have chosen this process to give our participants good guidelines on the kind of documentation to keep to validate performance of the measure. If your eligible clinicians prefer to use a different tool, make sure that documentation is outlined in the medical report.
Regardless of whether you choose to utilize the STEADI documents, your auditor will need to see evidence that a fall risk assessment was performed on an appropriate patient. They may ask to see the tool used to assess the patient’s risk of falling as well as evidence that the patient had suffered two or more falls in the past year or a fall with injury in the past year. If the entire assessment is not uploaded into the record, ensure that the clinicians have documented the name of the assessment used. Some common ones include:
- 30-Second Chair Stand Test
- 4-Stage Balance Test
- Timed Up and Go (TUG) Test
- Berg Balance Scale
- Tinetti Balance Assessment