Performance Measurement Network

Question: Written discharge instructions for warfarin therapy

We have informational sheets that explicitly address each item in VTE-5. The nurses document in the education portion of the charting that the information sheet was given to the pt. Is it necessary to specifically document each item of the measure or include a copy of the information sheet in the chart for me to be able to abstract as "Yes". Could you please expand on what is required to meet each part of VTE - 5?

Answer:

Here are the required topics of D/C Instructions for VTE:

A. Discharge Instructions Address Compliance Issues 1. The importance of taking warfarin as instructed. 2. The importance of monitoring warfarin with scheduled PT/INR blood draws.

B. Discharge Instructions Address Dietary Advice

1. A “consistent amount” of foods with Vitamin K rather than avoidance should be advised. 2. Avoid major changes in dietary habits, or notify health professional before changing habits.

C. Discharge Instructions Address Follow-up Monitoring

1. Name of healthcare professional/clinic or office monitoring anticoagulation therapy 2. phone number of health professional/clinic or office, monitoring the anticoagulation therapy. 3. Next date for PT/INR laboratory blood draw.

D. Discharge Instructions Address Potential for Adverse Drug Reactions and Interactions 1.Diet and medications can affect the PT/INR level. 2.Do not take or discontinue any medication or over-the-counter medication except on the advice of the physician or pharmacist. 3.Warfarin increases the risk of bleeding.

1. Your organization can teach the material any way, face to face, DVD, or however they chose. 2. They must have a paper document that has all the above points written down on it so that pt can refer to it at home. 3. This paper must be signed by both parties, nurse(teacher) and patient (Family or recipient of info), or have a pt sticker, or label. This is true especially if the pt or family cannot sign, but name must be present to identify it with the record. 4. This record of education material must be then scanned in the chart, or part of the chart, so that there is record of the action taken by the organization to ensure that the patient has the information at home. If your organization's EMR has the option to upload this material, then the nurse can check off each topic,and document exactly what material was explained and sent home to the patient. A printed copy of that material must be sent home to the pt.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical, Related Manual - Data Quality Manual
Related documents: VTE-05, VTE Prophylaxis,
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