Performance Measurement Network

Question: Reason for Not Initiating IV Thrombolytic-conflicting GWTG instructions

This is follow up to a prior question: "";.

In the GWTG instructions it says: "It is not acceptable to use documentation of contraindications and/or warnings from outside physician or nurse notes that played a factor in the decision-making process for not giving thrombolytic therapy." Is physician documentation useable for "Reason for Not Initiating IV Thrombolytic" if the physician was not the "decision maker".

Answer:

The GWTG instruction, i.e., "It is not acceptable to use documentation of contraindications and/or warnings from outside physician or nurse notes that played a factor in the decision-making process for not giving thrombolytic therapy.", cannot be abstracted by a third-party. If the physician documented a "Reason for Not Initiating IV Thrombolytic" in the medical record, then he/she is accountable for that documentation.

The medical record must be abstracted at face value. See Introdution to the Alphabetical Data Dictionary, General ABstraction Guidelines detailed in the Specifications Manual for National Hospital Inpatient Quality Measures.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical, Related Manual - Data Quality Manual
Related documents: STK-04, TPA contraindication
File:

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