Performance Measurement Network

Question: Can the following note be used as a Reason for Not Prescribing Anticoagulation Therapy?

This is follow up to a prior question: "Reason for No Anticoagulation Therapy Prescribed at Discharge";.

Physician doccumented the following in his progress note: "MRI w/ acute CVA w/ possible hemorrhagic conversion. Echo w/ Afib but no thrombus noted. Rx'd w/ ASA, statin, permissive HTN and improving. … Discussed case w/ Neuro who rec: con't ASA for now for Afib/CVA prevention, change to coumadin in 2-3wks once hemorrhagic conversion is better".

Answer:

Only patients with atrial fibrillation/flutter and assigned an ICD-9-CM Principal Diagnosis Code for ischemic stroke at discharge are included in the STK-3 denominator. Hemorrhagic stroke patients are not included.

If the patient was assigned an ischemic code (See Appendix A, Table 8.1 of the specifications manual), select 'Yes' for "Reason for Not Prescribing Anticoagulation Therapy at Discharge" based on documentation,"con't ASA for now for Afib/CVA prevention".

http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK-03,
File:

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