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

Data Element Name: IV Thrombolytic Initiation Date
Collected For: ASR-IP-1, ASR-OP-1, CSTK-05, STK-4
Definition:The month, date, and year that IV thrombolytic therapy was initiated to a patient with ischemic stroke at this hospital. IV thrombolytics convert plasminogen to plasmin, which in turn breaks down fibrin and fibrinogen, thereby dissolving thrombus.
Suggested Data Collection Question:What is the date that IV thrombolytic therapy was initiated for this patient at this hospital?
Length:10 - MM-DD-YYYY (includes dashes) or UTD
Allowable Values:

MM = Month (01-12)
DD = Day (01-31)
YYYY = Year (20xx)
UTD = Unable to Determine

Notes for Abstraction:
  • Use the date at which initiation of the IV thrombolytic was first documented. If a discrepancy exists in date documentation from different sources, choose nursing documentation first before other sources. If multiple dates are documented by the same individual, use the earliest date recorded by that person.
  • If the date IV thrombolytic therapy was initiated is unable to be determined from medical record documentation, select “UTD”.
  • The medical record must be abstracted as documented (taken at “face value”). When the date documented is obviously in error (not a valid date/format) and no other documentation is found that provides this information, the abstractor should select “UTD”.
    Documentation indicates the IV thrombolytic initiation date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the IV thrombolytic initiation date is outside of the range listed in the Allowable Values for “Day",” it is not a valid date and the abstractor should select “UTD”.
    Note: Transmission of a case with an invalid date as described above will be rejected from the CMS Clinical Warehouse and the Joint Commission''s Data Warehouse. Use of “UTD” for IV Thrombolytic Initiation Date allows the case to be accepted into the warehouse
Suggested Data Sources:

  • Emergency department record
  • Nursing flow sheet
  • Progress notes
  • IV flow sheets
  • Medication administration record
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

IV Thrombolytic Initiation Date
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)