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Specifications Manual for Joint Commission National Quality Measures (v2015A)
Home » ACEI Prescribed at Discharge

Release Notes:
Data Element
Version 2015A

Data Element Name: ACEI Prescribed at Discharge
Collected For: HF-3,
Definition:Documentation that an angiotensin converting enzyme inhibitor (ACEI) was prescribed at hospital discharge. ACEIs widen or dilate blood vessels, lowering blood pressure and making it easier for the heart to pump blood. They also inhibit the adverse effects of neurohormonal activation on the heart. These effects help reduce the risk of adverse outcomes such as death or hospitalization.
Suggested Data Collection Question:Was an angiotensin converting enzyme inhibitor (ACEI) prescribed at discharge?
Allowable Values:

Y   (Yes)   ACEI prescribed at discharge.

N   (No)   ACEI not prescribed at discharge, or unable to determine from medical record documentation.
Notes for Abstraction:
  • In determining whether an ACEI was prescribed at discharge, it is not uncommon to see conflicting documentation amongst different medical record sources. For example, the discharge summary may list an ACEI that is not included in any of the other discharge medication sources (e.g., discharge orders). All discharge medication documentation available in the chart should be reviewed and taken into account by the abstractor.
    • In cases where there is an ACEI in one source that is not mentioned in other sources, it should be interpreted as a discharge medication (select "Yes") unless documentation elsewhere in the medical record suggests that it was NOT prescribed at discharge - Consider it a discharge medication in the absence of contradictory documentation.
    • If documentation is contradictory (e.g., physician noted "“d/c Zestril"” in the discharge orders, but Zestril is listed in the discharge summary'’s discharge medication list), or after careful examination of circumstances, context, timing, etc., documentation raises enough questions, the case should be deemed “unable to determine” (select “"No"”).
    • Consider documentation of a hold on an ACEI after discharge in one location and a listing of that ACEI as a discharge medication in another location as contradictory ONLY if the timeframe on the hold is not defined (e.g., "“Hold Zestril"”). Examples of a hold with a defined timeframe include "“Hold captopril x2 days"” and "“Hold Quinaretic until after stress test."”
    • If an ACEI is NOT listed as a discharge medication, and there is only documentation of a hold or plan to delay initiation/restarting of an ACEI after discharge (e.g., "“Hold captopril x2 days,"” "“Start ACEI as outpatient,"” "“Hold Zestril"”), select "“No".”
    • If two discharge summaries are included in the medical record, use the one with the latest date/time. If one or both are not dated or timed, and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Use the dictated date/time over transcribed date/time, file date/time, etc. Examples:
      • Two discharge summaries, one dictated 5/22 (day of discharge) and one dictated 5/27 - Use the 5/27 discharge summary.
      • Two discharge medication reconciliation forms, one not dated and one dated 4/24 (day of discharge) - Use both.
  • Disregard an ACEI medication documented only as a recommended medication for discharge (e.g., "“Recommend sending patient home on Vasotec"”). Documentation must be clearer that the ACEI was actually prescribed at discharge.
  • Disregard documentation of ACEI prescribed at discharge when noted only by medication class (e.g., “"ACEI Prescribed at Discharge: Yes”" on a core measures form). The ACEI must be listed by name.
Suggested Data Sources:

  • Discharge summary
  • Transfer sheet
  • Discharge instruction sheet
  • Medication reconciliation form
  • Nursing discharge notes
  • Physician order sheet
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Refer to Appendix C, Table 1.2 for a comprehensive list of ACEIs. None

ACEI Prescribed at Discharge
Specifications Manual for Joint Commission National Quality Measures (v2015A)
Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15)