Release Notes:
Data Element
Version 2018B1
| Name: | Care Transition Record-Discharge Medications |
|---|
| Collected For: |
ACHF-03 |
|---|
| Definition: | Documentation in the care transition record includes the discharge medications, dosage and indication for use or that no medications were prescribed at discharge. |
|---|
| Question: | Is there documentation in the medical record of a care transition record which includes the discharge medications, dosage and indication for use or that no medications were prescribed at discharge? |
|---|
| Format: |
| Length: | 1 |
|---|
| Type: | Alphanumeric |
|---|
| Occurs: | 1 |
|---|
|
|---|
| Allowable Values: |
Y (Yes) There is documentation that the care transition record included discharge medications, dosage, and indication for use.
N (No) There is no documentation that the care transition record included discharge medications, dosage, and indication for use, OR unable to determine from medical record documentation.
|
|---|
| Notes for Abstraction: |
- Medications are defined as any prescription medications, sample medications, herbal remedies, vitamins, nutriceuticals, over-the-counter drugs and any product designated by the Food and Drug Administration (FDA) as a drug (taken from the 2014 Comprehensive Accreditation Manual for Hospitals: The Official Handbook (CAMH)).
- Discharge medications are all medications prescribed for the patient at discharge, including PRN medications, and are NOT limited to only those medications prescribed for heart failure.
- All medications must have the names, dosage and indication for use listed in the care transition record in order to select Yes'. The indication for use can be as short as one to two words, but must be present for all medications, not just heart failure medications.
- If documentation reflects that no medications were prescribed for the patient at the time of discharge, select Yes.
|
|---|
| Suggested Data Sources: |
- Aftercare discharge plan
- Care transition record
- Continuing care plan
- Discharge plan
- Discharge summary
- Medication reconciliation form
- Physician orders
- Progress notes
- Referral form
|
|---|
| Additional Notes: |
|
|---|
| Guidelines for Abstraction: |
|---|
| Inclusion |
Exclusion |
- Routinely scheduled medications
- PRN medications
|
None |
|