Specifications Manual for Joint Commission National Quality Measures (v2018A1)
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Release Notes:
Data Element
Version 2018A1

Data Element Name: Reason for Not Administering Antithrombotic Therapy by End of Hospital Day 2
Collected For: ASR-IP-2, STK-5
Definition:Reason for not administering antithrombotic therapy by end of hospital day 2.
  • Other reasons documented by physician/APN/PA or pharmacist.
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 administering antithrombotic therapy by end of hospital day 2?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes)     There is physician/APN/PA or pharmacist documentation of a reason for not administering antithrombotic therapy by end of hospital day 2.

N (No)     There is no physician/APN/PA or pharmacist documentation of a reason for not administering antithrombotic therapy by end of hospital day 2 or unable to determine from the medical record documentation.
Notes for Abstraction:
  • Documentation for allowable value “Yes” must be found within the timeframe of arrival to the end of hospital day 2. It is not necessary to review documentation outside of this timeframe to answer this data element.
  • To compute end of hospital day 2, count the arrival date as hospital day 1. If a reason for not administering antithrombotic therapy was documented by 11:59 P.M. of hospital day 2, select “Yes” for this data element.
  • Reasons for not administering antithrombotic therapy must be documented by a physician/APN/PA or pharmacist with one exception: Patient/family refusal of any form of antithrombotic therapy (e.g., “ASA refused,” “Patient refusing antithrombotic therapy”) may be documented by a nurse. However, it must be documented in the timeframe of arrival to the end of hospital day 2.
    Example:
    Patient arrived on 03/01/20XX. Nursing notes on 03/02/20XX indicates that patient refused antithrombotic therapy, select “Yes.”
  • If reasons are not mentioned in the context of antithrombotics, do not make inferences (e.g., do not assume that antithrombotic therapy was not administered because of a bleeding disorder unless documentation explicitly states so).
    • Reasons must be explicitly documented (e.g., “Hemorrhagic transformation – do not give aspirin,” “Active GI bleed – antithrombotic therapy contraindicated,” “H/O bleeding disorder – anticoagulation therapy contraindicated,” “Low platelet count - do not give antiplatelet medications,” “No ASA” [no reason given]).
    • Consider the terms "anticoagulant", "antiplatelet", and "blood thinners" synonymous with antithrombotic therapy. Physician/APN/PA or pharmacist documentation,(e.g., "no blood thinners", "no anticoagulant medications", "no antiplatelet medications"), select "Yes".
    • Physician/APN/PA or pharmacist documentation of a hold on an antithrombotic medication or discontinuation of an antithrombotic medication that occurs the day of or day after hospital arrival constitutes a “clearly implied” reason for not administering antithrombotic therapy by end of hospital day 2. A hold/discontinuation of all P.O. medications counts if an antithrombotic was on order at the time of the notation.
  • For patients with an order for ANY antithrombotic that was NOT administered without a documented reason or administered after day 2, select “No.”
    Example:
    Patient has documentation of an order for aspirin on day 2. No documentation that aspirin was administered by end of day 2. No documentation of a hold or discontinuation of the aspirin order or other documented reason, select “No.”
  • NPO is NOT a reason for not administering antithrombotic therapy without explicit documentation that no antithrombotic medication should be given. Another route of administration can be used.
  • An allergy or adverse reaction to one type of antithrombotic would NOT be a reason for not administering all antithrombotics. Another medication can be ordered.
  • For patients on warfarin therapy prior to hospital arrival, but placed on hold the day of or after arrival due to “high INR,” select “Yes.”
Suggested Data Sources:

ONLY PHYSICIAN/APN/PA OR PHARMACIST DOCUMENTATION OF A REASON FOR NOT ADMINISTERING ANTITHROMBOTIC THERAPY:
  • Consultation notes
  • Emergency room records
  • History and physical
  • Medication reconciliation form
  • Progress Notes

SUGGESTED DATA SOURCES FOR PATIENT/FAMILY REFUSAL (other than physician/APN/PA or pharmacist documentation of a reason for not administering antithrombotic therapy as noted above):
  • Medication Administration Record
  • Nurses notes

Excluded Data Sources:
Any documentation dated/timed prior to hospital arrival or after hospital day 2.
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • None
  • Refer to Appendix C, Table 8.2 for a comprehensive list of Antithrombotic Medications
  • Delay in stroke diagnosis
  • Antithrombotic 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 Administering Antithrombotic Therapy by End of Hospital Day 2
Specifications Manual for Joint Commission National Quality Measures (v2018A1)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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