Performance Measurement Network

Question: Statin prescibed the day after discharge

Patient with a LDL-c of 209 mg/dL. No Statins documented on the patient's discharge medication instruction sheets, progress notes, discharge orders, or physicians discharge medication form. However, the physician did document, on his Discharge Summary(dictated 8 days after discharge), that the patient was placed on Lipitor and that this medication was called in after the day of discharge. Can this information be used for Statin Medication Prescribed at Discharge? Also, is this a mismatch for written discharge medication education?

Answer:

The intent of abstraction is to use only documentation that was part of the medical record during the hospitalization (is present upon discharge) and that is present at the time of abstraction. There are instances where an addendum or late entry is added after discharge. This late entry or addendum can be used, for abstraction purposes, as long as it has been added within 30 days of discharge, [Refer to the Medicare Conditions of Participation for Medical Records, 42CFR482.24©(2)(viii)], unless otherwise specified in the data element. It is not the intent to have documentation added at the time of abstraction to ensure the passing of a measure.

Select, "Yes" for Statin Medication Prescribed at Discharge. It is not a mismatch for Education Addresses Medications Prescribed at Discharge, as long as written instructions/materials for all medications ordered at the time of discharge were given to the patient/caregiver.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical, Related Manual - Data Quality Manual
Related documents: STK-06, STK-08, statin medication
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