Antithrombotic Therapy Prescribed at Discharge

Specifications Manual for Joint Commission National Quality Measures (v2016B1)

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Release Notes:
Data Element
Version 2016B1

Data Element Name:

Antithrombotic Therapy Prescribed at Discharge

Collected For:

STK-2,

Definition:

Documentation that antithrombotic therapy was prescribed at hospital discharge. Antithrombotics include both anticoagulant and antiplatelet drugs.

Suggested Data Collection Question:

Was antithrombotic therapy prescribed at hospital discharge?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

(Y) Antithrombotic therapy was prescribed at hospital discharge.

(N) Antithrombotic therapy was not prescribed at hospital discharge, OR unable to determine from medical record documentation.

Notes for Abstraction:

In determining whether antithrombotic therapy 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 antithrombotic 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 antithrombotic 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 Plavix” in the discharge orders, but Plavix 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 antithrombotic after discharge in one location and a listing of that antithrombotic as a discharge medication in another location as contradictory ONLY if the timeframe on the hold is not defined (e.g., “Hold Plavix”). Examples of a hold with a defined timeframe include “Hold Plavix x2 days” and “Hold ASA until after stress test.”
- If an antithrombotic is NOT listed as a discharge medication, and there is only documentation of a hold or plan to delay initiation/restarting of antithrombotic therapy after discharge (e.g., “Hold Plavix x2 days,” “Start Plavix as outpatient,” “Hold Plavix”), 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 antithrombotic medication documented only as a recommended medication for discharge (e.g., “Recommend sending patient home on aspirin”). Documentation must be clearer that an antithrombotic was actually prescribed at discharge.
Disregard documentation of antithrombotic prescribed at discharge when noted only by medication class (e.g., “Antithrombotic Prescribed at Discharge: Yes” on a core measures form). The antithrombotic must be listed by name.

Suggested Data Sources:

Consultation notes
Progress notes
Physician orders
Discharge summary
Medication reconciliation form

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
Refer to Appendix C, Table 8.2 for a list of medications used for antithrombotic therapy.	Heparin Flush Heparin SQ Hep-Lock

Antithrombotic Therapy Prescribed at Discharge

Specifications Manual for Joint Commission National Quality Measures (v2016B1)
Discharges 01-01-17 (1Q17) through 06-30-17 (2Q17)