Release Notes:
Data Element
Version 2016B1
Data Element Name: | Reason for Not Administering a Procoagulant Reversal Agent |
Collected For: | CSTK-04, |
Definition: | Reason for not administering a procoagulant reversal agent.
- Adverse reaction to a procoagulant reversal agent
- Other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist.
Procoagulant reversal agents are medications that increase coagulation factors to promote clotting. |
Suggested Data Collection Question: | Is there documentation by a physician/APN/PA or pharmacist in the medical record of a reason for not administering a procoagulant reversal agent? |
Format: | Length: | 1 | Type: | Alphanumeric | Occurs: | 1 |
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Allowable Values: |
Y (Yes) There is documentation of a reason for not administering a procoagulant reversal agent.
N (No) There is no documentation of a reason for not administering a procoagulant reversal agent OR unable to determine from medical record documentation.
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Notes for Abstraction: |
- Reasons for not administering a procoagulant reversal agent must be documented by the physician/APN/PA or pharmacist.
- If reasons are not mentioned in the context of a procoagulant reversal agent, do not make inferences (e.g., do not assume that a procoagulant reversal agent was not administered because of an adverse reaction to a procoagulant reversal agent unless documentation explicitly states so.)
- Reasons must be explicitly documented (e.g., “Allergic to cow milk. Do not give NovoSeven.
- When conflicting information is documented in the medical record, select “Yes”.
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Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Progress notes
- Discharge summary
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Additional Notes: |
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Guidelines for Abstraction: |
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Reason for Not Administering a Procoagulant Reversal Agent
Specifications Manual for Joint Commission National Quality Measures (v2016B1)
Discharges 01-01-17 (1Q17) through 06-30-17 (2Q17)
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