Aspirin Prescribed at Discharge

Specifications Manual for Joint Commission National Quality Measures (v2015A)

Print this page

Home » Aspirin Prescribed at Discharge

Release Notes:
Data Element
Version 2015A

Data Element Name:

Aspirin Prescribed at Discharge

Collected For:

AMI-2,

Definition:

Documentation that aspirin was prescribed at discharge. Aspirin reduces the tendency of blood to clot by blocking the action of a type of blood cell involved in clotting. Aspirin improves chances of surviving a heart attack and reduces the risk of recurrence in patients who have experienced a heart attack.

Suggested Data Collection Question:

Was aspirin prescribed at discharge?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) Aspirin prescribed at discharge.

N (No) Aspirin not prescribed at discharge or unable to determine from medical record documentation.

Notes for Abstraction:

In determining whether aspirin 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 aspirin medication 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 aspirin 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 aspirin” in the discharge orders, but aspirin 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 aspirin after discharge in one location and a listing of aspirin as a discharge medication in another location as contradictory ONLY if the timeframe on the hold is not defined (e.g., “Hold ASA”). Examples of a hold with a defined timeframe include “Hold EC ASA x2 days” and “Hold aspirin until after endoscopy.”
- If aspirin is NOT listed as a discharge medication, and there is only documentation of a hold or plan to delay initiation/restarting of aspirin after discharge (e.g., “Hold EC ASA x2 days,” “Start baby aspirin as outpatient,” “Hold ASA”), 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 aspirin documented only as recommended medication for discharge (e.g., “Recommend sending patient home on ASA”). Documentation must be clearer that aspirin was actually prescribed at discharge.

Suggested Data Sources:

Discharge instruction sheet
Discharge summary
Medication reconciliation form
Nursing discharge notes
Physician orders
Transfer sheets

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
Refer to Appendix C, Table 1.1 for a comprehensive list of Aspirin and Aspirin-Containing Medications.	Aggrenox (aspirin/dipyridamole)

Aspirin Prescribed at Discharge

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