Question: Reason For Not Administering Antithrombotic By End of Hospital Day 2

This is follow up to a prior question: "";.

A patient was hospitalized for new onset seizures. A diagnosis of stroke was confirmed on day 3 following brain MRI. The physician documented in the discharge summary that the stroke was not diagnosed until hospital day 3. Can the physician's documentation by used as a "Reason for Not Administering Antithrombotic By End of Hospital Day 2"? The principal diagnosis code assigned at discharge was 434.91.

Answer:

No. An ICD-9-CM Principal Diagnosis Code of 434.91, "Cerebral Artery Occlusion Unspecified with Cerebral Infarction", is used to identify the stroke measure population. For STK-5: Antithrombotic Therapy Administered By End of Hospital Day 2, it is not necessary to review documentation outside of the 2 day timeframe. Discharge summary is not a "Suggested Data Source" for this measure. Any documentation dated/timed prior to hospital arrival or after hospital day 2 is excluded. Select 'No' for *"Reason for Not Administering Antithrombotic Therapy By End of Hospital Day 2"*.