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

Data Element Name: Reason for Not Prescribing Anticoagulation Therapy at Discharge
Collected For: STK-3
Definition:Reason for not prescribing anticoagulation therapy at hospital discharge.
  • Other reason documented by physician/APN/PA or pharmacist

The administration of anticoagulation therapy, unless there are contraindications, is an established effective strategy in preventing recurrent stroke in high stroke risk-atrial fibrillation patients with TIA or prior stroke.
Suggested Data Collection Question:Is there documentation by a physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist in the medical record of a reason for not prescribing anticoagulation therapy at hospital discharge?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes)     There is documentation of a reason for not prescribing anticoagulation therapy at hospital discharge.

N (No)     There is no documentation of a reason for not prescribing anticoagulation therapy at hospital discharge, OR unable to determine from the medical record documentation.
Notes for Abstraction:
  • Reasons for not prescribing anticoagulation therapy at hospital discharge must be documented by a physician/APN/PA or pharmacist with one exception: Patient/family refusal of any form of anticoagulation therapy (e.g., “Coumadin refused,” “Patient refusing anticoagulation therapy”) may be documented by a nurse.
  • If reasons are not mentioned in the context of anticoagulation therapy, do not make inferences (e.g., do not assume that anticoagulation therapy was not prescribed because of a bleeding disorder unless documentation explicitly states so).
    • Reasons must be explicitly documented (e.g., “Active GI bleed – anticoagulation therapy contraindicated,” “No warfarin” [no reason given]).
    • Consider the term "blood thinners" synonymous with anticoagulant therapy. Physician/APN/PA or pharmacist documentation, e.g., "no blood thinners", select "Yes".
    • Physician/APN/PA or pharmacist documentation of a hold on an anticoagulant medication or discontinuation of an anticoagulant medication that occurs during the hospital stay constitutes a “clearly implied” reason for not prescribing anticoagulation therapy at discharge. A hold/discontinuation of all p.o. medications counts if an oral anticoagulant medication (e.g., warfarin) was on order at the time of the notation.
      EXCEPTIONS:
      • Documentation of a conditional hold or discontinuation of an anticoagulant medication does not count as a reason for not prescribing an anticoagulant medication at discharge (e.g., “Hold Coumadin if guaiac positive,” “Stop warfarin if rash persists,” “No warfarin for 24 hours following thrombolytic therapy”).
      • Discontinuation of a particular anticoagulant medication documented in combination with the start of a different anticoagulant medication (i.e., switch type of anticoagulant medication) does not count as a reason for not prescribing an anticoagulant medication at discharge.
        Examples:
        • “Stop warfarin” and “Start warfarin 2 mg po daily” in same physician order
        • “Change Coumadin to Pradaxa” in progress note
        • “Do not continue after discharge” checked for warfarin and “Continue after discharge” checked for Coumadin on a physician-signed discharge medication reconciliation form
      • Discontinuation of an anticoagulant medication at a particular dose documented in combination with the start of a different dose of that anticoagulant (i.e., change in dosage) does not count as a reason for not prescribing an anticoagulant medication at discharge.
        Examples:
        • “Stop warfarin 5 mg po daily” and “Start warfarin 2.5 mg po daily” in same physician order
        • “Decrease dabigatran 150 mg po BID to 75 mg po BID” in progress note
        • “Do not continue after discharge” checked for Coumadin 5 mg and “Continue after discharge” check for Coumadin 2.5 mg on a physician-signed discharge medication reconciliation form
    • Deferral of anticoagulation therapy from one physician/APN/PA or pharmacist to another does NOT count as a reason for not prescribing anticoagulation therapy at discharge unless the problem underlying the deferral is also noted.
      Examples:
      • “Consulting neurologist to evaluate pt. for warfarin therapy.” - select “No.”
      • “Rule out GI bleed. Start Coumadin if OK with gastroenterology” - select "Yes.”
    • If there is documentation of a plan to initiate/restart anticoagulation therapy, and the reason/problem underlying the delay in starting/restarting anticoagulation therapy is also noted, this constitutes a “clearly implied” reason for not prescribing anticoagulation therapy at discharge.
      Acceptable examples (select “Yes”):
      - “Stool Occult Blood positive. May start Coumadin as outpatient.”
      - “Start warfarin if hematuria subsides.”
      Unacceptable examples (select “No”):
      - “Consider starting Coumadin in a.m.”
      - “May add warfarin when pt. can tolerate”
    • Reasons do NOT need to be documented at discharge or otherwise linked to the discharge timeframe: Documentation of reasons anytime during the hospital stay are acceptable (e.g., mid-hospitalization note stating “no warfarin due to rectal bleeding” - select “Yes,” even if documentation indicates that the rectal bleeding has resolved by the time of discharge and warfarin was restarted).
    • Crossing out of an anticoagulant medication counts as a "clearly implied reason" for not prescribing anticoagulation therapy at discharge only if on a pre-printed form.
  • An allergy or adverse reaction to one type of anticoagulant would NOT be a reason for not administering all anticoagulants. Another medication can be ordered.
  • When conflicting information is documented in a medical record, select “Yes.”
  • When the current record includes documentation of a pre-arrival reason for no anticoagulation therapy, the following counts regardless of whether this documentation is included in a pre-arrival record made part of the current record or whether it is noted by hospital staff during the current hospital stay:
    • Pre-arrival hold/discontinuation or notation such as "No Coumadin" IF the underlying reason/problem is also noted (e.g., “Coumadin held in transferring hospital due to possible GI bleed”).
    • Pre-arrival "other reason" (other than hold/discontinuation or notation of "No warfarin") (e.g., "Hx GI bleeding with warfarin" in transferring ED record).
Suggested Data Sources:

ONLY PHYSICIAN/APN/PA OR PHARMACIST DOCUMENTATION OF A REASON FOR NOT PRESCRIBING ANTICOAGULATION THERAPY AT HOSPITAL DISCHARGE:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Progress notes
  • Physician orders
  • Discharge summary
  • After Visit Summary (AVS)
  • Medication administration record (MAR)

Excluded Data Sources: Any documentation dated/timed after discharge, except discharge summary.
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None

Refer to Appendix C, Table 8.3 for a comprehensive list of Anticoagulant Medications.

 Anticoagulant medication allergy described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table.

Reason for Not Prescribing Anticoagulation Therapy at Discharge
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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