Performance Measurement Network

Question: Can post discharge documentation of a statin prescription be used in abstraction?

A patient was transferred from acute inpatient care following stroke to our acute inpatient rehab unit. The patient's medication orders at discharge didn't include the statin but on admission to acute rehab, a statin was started. Can this post- discharge information from the acute rehab unit be used to answer "Yes" to Statin Medication Prescribed at Discharge? We have an electronic medical record, and the acute rehab records are available in the EMR.

Answer:

If billed as two separate admissions, select 'No' for "Statin Medication Prescribed at Discharge"; however, if the inpatient and rehab admission were billed as one episode of care, then select 'Yes'.

Episode of Care An Episode of Care (EOC) is defined as the health care services given during a certain period of time, usually during a hospital stay (e.g., from the day of arrival or admission to the day of discharge). The medical record should be abstracted as it was billed. If a patient is transferred from an acute care hospital to another acute care hospital, which is within the same healthcare system and share the same CMS Certification Number (CCN), this should be abstracted as one episode of care.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK-06,
File:

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