Performance Measurement Network

Question: Is refusal of all IV's a Reason for Not Initiating IV Throbolytic Therapy?

Is documentation of patient refusal of all IV medications sufficient documentation for *Reason for Not Administering IV Thrombolytics*?

Answer:

Reasons for not initiating IV thrombolytic therapy must be documented by a physician/APN/PA or pharmacist. Documentation of patient/family refusal of IV thrombolytic may be done by the nurse, as well as, physician/APN/PA or pharmacist. Reasons must be mentioned in the context of IV thrombolytics (i.e., reason and IV t-PA are linked, "Patient refused t-PA") When reasons do not specifically mention t-PA, do not make inferences. Do not assume that patient refusal of IV medications followed an explanation of risks and benefits of IV thrombolytic administration.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK-04, reason for not administering iV thrombolytics
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