Atrial Fibrillation/Flutter

Specifications Manual for Joint Commission National Quality Measures (v2016B1)

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Release Notes:
Data Element
Version 2016B1

Data Element Name:

Atrial Fibrillation/Flutter

Collected For:

STK-3,

Definition:

Documentation by a physician/APN/PA that the patient has a history of ANY atrial fibrillation (e.g., remote, persistent, or paroxysmal) or atrial flutter OR a diagnosis or signed ECG tracing of ANY atrial fibrillation or flutter.

Suggested Data Collection Question:

Was there physician/APN/PA documentation of a diagnosis, signed ECG tracing, or a history of ANY atrial fibrillation/flutter in the medical record?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) There is physician/APN/PA documentation of a diagnosis or a history of ANY atrial fibrillation/flutter.

N (No) There is no physician/APN/PA documentation of a diagnosis or a history of ANY atrial fibrillation/flutter, OR unable to determine from medical record documentation.

Notes for Abstraction:

If there is a documented history or diagnosis of ANY condition (e.g., remote, persistent, or paroxysmal) described in the definition statement, select “Yes.”
If there is documentation of atrial fibrillation or flutter on a signed ECG, select “Yes.”
If there is a diagnosis of atrial fibrillation or flutter anywhere in the medical record, or documentation of a past history of atrial fibrillation or flutter anywhere in the medical record, select “Yes.”
If there is physician/APN/PA documentation of any of the following examples, disregard and continue to review the medical record for a confirmed diagnosis. If no other documentation exists, select “No.”
- “suspected/suspicion of atrial fibrillation or flutter”
- “rule out atrial fibrillation/flutter”
- “questionable atrial fibrillation/flutter”
- “possible atrial fibrillation/flutter”
If there is documentation to monitor the patient for atrial fibrillation/flutter after discharge and no other documentation of a confirmed diagnosis or history of atrial fibrillation/flutter in the medical record, select “No.”
Example:
Possible cardioembolic origin. Telemetry monitoring for 30 days to exclude PAF.
If there is documentation of a history of an ablation procedure for atrial fibrillation/flutter, select “Yes.”
If there is documentation of a history of atrial fibrillation or flutter that terminated within 8 weeks following CABG, select “No.”
If there is documentation of a history of transient and entirely reversible episode of atrial fibrillation or flutter due to thyrotoxicosis, select “No.”

Suggested Data Sources:

PHYSICIAN/APN/PA DOCUMENTATION ONLY:

History and physical
Progress notes
Discharge summary
Transfer sheet
ECG report
Holter monitor report
Problem List

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
None	PAC Paroxysmal atrial tachycardia Paroxysmal supraventricular tachycardia PAT Premature atrial contraction PST

Atrial Fibrillation/Flutter

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