Performance Measurement Network

Question: Refusal of SCD's

If there is documentation in the medical record that the patient refused SCD's, is refusal of all DVT prophylaxis then also implied? The coding instructions state that "If documentation indicates that the patient/caregiver refused DVT prophylaxis, chooose NC." Is documentation of refusal of pharmacological and mechanical DVT prophylaxis required?

Answer:

If patient/family refusal of any form of prophylaxis, then select 'Yes' for Reason for No VTE Prophylaxis-Hospital Admission. With core measure alignment, the 'NC' path was replaced by the data element "Reason for No VTE Prophylaxis-Hospital Admission". (Refer to STK-1 MIF pdf algorithm).

Effective January 1, 2010, all certified primary stroke centers were required to use the Specifications Manual for National Hospital Inpatient Quality Measures for stroke data collection. http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Specification+Manuals.htm.

The 'NC' path was removed from all measure algorithms and replaced with separate data element definitions for "Reason for Not Prescribing Anticoagulation Therapy, Antithrombotic Therapy, Statin Medication at Discharge, etc.). See the STK_List pdf for a complete list of measure-specific stroke data elements. Definitions for each data element are detailed in the Alphabetical Data Dictionary pdf of the specifications manual.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK, STK-01, Was DVT prophylaxis administered by the end of hospital day 2?
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