Release Notes:
Data Element
Version 2018B
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 |
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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.
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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".
- Documentation of "do not continue" or “do not convert” a home anticoagulant medication to an inpatient medication, or an inpatient anticoagulant medication to a discharge medication, does not count as a reason for not prescribing anticoagulation therapy at discharge. Do not infer that an anticoagulant medication was not prescribed or discontinued without explicit documentation of a reason for not prescribing an anticoagulant medication at discharge.
Example: Patient on Coumadin 2.5 mg while an inpatient. During discharge medication reconciliation, physician checks “do not convert” box next to Coumadin, select “No.”
- 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).
- 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 antithrombotic 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:
Example: "Hx GI bleeding with warfarin" documented in a transferring record.
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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.
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Additional Notes: |
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Guidelines for Abstraction: |
Inclusion |
Exclusion |
None
Refer to Appendix C, Table 8.3 for a comprehensive list of Anticoagulant Medications.
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Anticoagulant medication allergy described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table. |
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Reason for Not Prescribing Anticoagulation Therapy at Discharge
Specifications Manual for Joint Commission National Quality Measures (v2018B)
Discharges 01-01-19 (1Q19) through 06-30-19 (2Q19)
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