| Notes for Abstraction: | Abstraction is a two-step process:
1. Compile a list of all of the medications being prescribed at discharge, based on available medical record documentation.
- ALL discharge medication documentation in the chart should be reviewed and taken into account by the abstractor.
- Discharge medication information included in a discharge summary dated after discharge should be used as long as it was added within 30 days after discharge.
- 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.
- If discharge medications are noted using only references such as “continue home meds,” “resume other meds,” or “same medications,” rather than lists of the names of the discharge medications, the abstractor should use all sources to compile a list of medications the patient was on prior to arrival (or in the case of acute care transfers, use the medications the patient was on prior to arrival at the first hospital).
- Discharge medications can be listed in any of the acceptable data sources to be considered a discharge medication. If there is a medication in one source that is not mentioned in other sources, consider it a discharge medication.
Example:
- Discharge orders list Lasix but the discharge medication reconciliation form does not mention Lasix. Consider Lasix a discharge medication.
- If there is documentation in the medical record that specifically states a medication was NOT prescribed at discharge, do not consider it a discharge medication.
- If documentation is contradictory (e.g., physician noted “d/c ASA” in the discharge orders, but it is listed in the discharge summary’s discharge medication list), or, after careful examination of circumstances, context, timing, etc., documentation is still unclear, the case should be deemed "unable to determine” (select "No”).
- If there is documentation of a plan to start/restart a medication after discharge or a hold has been placed on a medication for a defined timeframe after discharge (e.g., “Start Plavix as outpatient,” “Hold Lasix x 2 days,” “Hold ASA until after endoscopy”), consider this a discharge medication requiring education.
- Disregard a medication documented only as a recommended medication for discharge. e.g., “Recommend sending patient home on Vasotec.” Documentation must reflect that the medication was actually prescribed at discharge.
- If a medication name is missing from a discharge medication source, disregard the medication.
- Disregard a discharge medication list labeled as “preliminary” or “interim”.
- As needed (PRN) medications are required on the discharge instructions, with ONE exception: When discharge medications outside of the written discharge instructions are noted using ONLY references such as “continue current medications” or “continue present meds,” rather than lists of the names of the discharge medications, and the abstractor is referencing what medications the patient was taking on the day of discharge (for comparison against the written discharge instructions, to confirm completeness of that list), medications which are clearly listed as PRN (given on an as needed basis only) do NOT need to be included in the instructions.
- Medications which the patient will not be taking at home (and/or the caregiver will not be giving at home) are NOT required in the medication list included in the written discharge instructions (e.g., monthly B12 injections, dialysis meds, chemotherapy).
2. Check this list of discharge medications against the written discharge instructions given to the patient to ensure that the discharge instructions addressed at least the names of all of the discharge medications prescribed. If medications are included in the discharge instructions that are not on the a list of discharge medications, or discharge medications are missing from the list in the instructions and it cannot be determined that the list of medications in the instructions is complete, then the case should be deemed “unable to determine” (select “No”).
Example:
Lasix is a medication listed on the discharge instruction sheet but Lasix is not in the discharge summary or documented as a discharge medication elsewhere in the medical record, select “No.”
- EXCEPTION: Medications listed on the discharge instructions but not mentioned as discharge medications elsewhere in the medical record are acceptable if the physician/APN/PA has signed or initialed the discharge instructions. Signatures that are dated/ timed after discharge are not acceptable.
Example:
- Discharge instruction sheet lists Plavix and aspirin. No other mention of Plavix or aspirin as a discharge medication in the medical record. Discharge instruction sheet is signed by Dr. X – Select “Yes.”
- In making medication name comparisons, consider two medications that are brand/trade name vs. generic name in nature or that have the same generic equivalent as matches.
Examples of matches:
- Coumadin vs. Warfarin
- ASA vs. EC ASA
- Plavix vs. Clopidogrel
- Mevacor vs. Lovastatin
- Lopressor vs. Metoprolol
- Metoprolol vs. Metoprolol Succinate
Example of a mismatch:
- Lopressor vs. Toprol
- If there is documentation that the patient was discharged on insulin(s) of ANY kind, ANY reference to insulin as a discharge medication in the written discharge instructions can be considered a match, for the purposes of the Stroke Education measure (STK-8). E.g., D/C summary notes patient discharged on “Humulin Insulin” and “Insulin 70/30” is listed on the discharge instruction sheet – Consider this a match. However, contradictory documentation abstraction guidelines still apply to insulin cases (e.g., D/C summary notes patient discharged on “Novolog 50 unit’s t.i.d.” and “Novolog 50 unit’s t.i.d.” is discontinued on discharge medication reconciliation form – Select “No”).
- Medications must be listed on the discharge instruction by name. Documentation to continue home medications without documentation of home medications listed by name, select “No.”
- Do not give credit in cases where there is a reference to a medication by class only on the written discharge instructions, (e.g., “Continue ACEI Inhibitor”), select “No.”
- Do not give credit in cases where the patient was given written discharge medication instructions only in the form of written prescriptions.
- Documentation must clearly convey that the patient/caregiver was given a copy of the discharge instructions to take home which listed all discharge medications prescribed for the patient by name. When the discharge instructions are present in the medical record and there is no documentation which clearly suggests that a copy was given, the inference should be made that it was given IF the patient's name or the medical record number appears on the material AND hospital staff or the patient/caregiver has signed the material.
- Use only documentation provided in the medical record itself. Do not review and use outside materials in abstraction. Do not make assumptions about what content may be covered in material documented as given to the patient/caregiver.
- Written instructions given or sent to the patient/caregiver after discharge, select “No.”
- If the patient refused written discharge instructions/material which addressed discharge medications, select “Yes.”
- If documentation indicates that written instructions/material on discharge medications were not given because the patient is cognitively impaired (e.g., comatose, obtunded, confused, short-term memory loss) and has no caregiver available, select “Yes.”
- The caregiver is defined as the patient’s family or any other person (e.g.,home health, VNA provider, prison official or other law enforcement personnel) who will be responsible for care of the patient after discharge.
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