Performance Measurement Network

Question: Does the reason for not presciribing anticoagulation therapy have to be documented on the dau of discharge?

Patient # 1: The only notation in the chart is a neuro consult note during the hospital stay that states: "...there has been no evidence to suggest that she is going in and out of atrial fibrillation. Therefore, I would continue with an antiplatelet agent. In addition, if there have been issues with compliance, coumadin certainly would not be a good choice of medication."

Patient #2. The only notation in the chart is a neuro consult note during the hospital stay that states: "She is not in atrial fib now but could not exclude an embolic event secondary to atrial fib if this history is accurate. Either way, she is not a likely candidate for coumadin since she is at risk for falling"

Are these documentation examples acceptable reasons for not prescribing anticougulation therapy at discharge, since the documentation was earlier in the hospital stay and not on the day of discharge from the hospital?

Answer:

Yes. For the discharge measures, i.e., STK-2, STK-3, STK-6, reason documentation any time during the hospitalization is acceptable. It is not limited to the day of discharge.

However the time limited measures, i.e., STK-1, STK-4, STK-5 do require that the reason be documented within the timeframe for the measure.

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

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