Specifications Manual for Joint Commission National Quality Measures (v2018A)
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Release Notes:
Data Element
Version 2018A

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 (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
Questions? Ask Question to Joint Commission staff Copyright © 2018 by The Joint Commission.
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