Question: AMA and Number of Antipsychotic Meds Prescribed at Discharge

Patient is admitted to inpatient psych unit and Invega is listed as home med. Approximately 6 hours later, the patient leaves AMA. Neither the Medication Reconciliation Form or the Discharge Summary lists discharge medications. For data element "Number of Antipsychotic Medications Prescribed at Discharge", should the abstractor assume that the patient will continue on Invega or that no antipsychotic medications were prescribed?

Answer:

The abstractor needs to abstract the medical record at face value and not assume what happened; therefore, if no medications are listed on the medication reconciliation form or discharge summary, they should select none.