Performance Measurement Network

Question: Discharged on Anticoagulation Therapy

Discharge instructions indicate that a patient was discharged on an anticoagulant, but no notation made that the prescription was given to the patient or a copy of prescription included in medical record. Should "Yes" or "No" be selected for this data element?

Answer:

Select "Yes". All discharge medication documentation available in the chart should be reviewed and taken into account by the abstractor. Documentation that the prescription was given to the patient and/or a copy of the prescription in the medical record is not explicitly needed. Other documentation in the medical record (e.g., discharge summary, consultation notes, physician orders, progress notes, MAR) that anticoagulation was prescribed at discharge is acceptable.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK, Date Last Known Well,
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