Specifications Manual for Joint Commission National Quality Measures (v2018B1)
Home » IV Alteplase Initiation Date

Release Notes:
Data Element
Version 2018B1

Name:IV Alteplase Initiation Date
Collected For: ASR-IP-1, ASR-OP-1, CSTK-05, STK-4
Definition:The month, date, and year that IV alteplase was initiated to a patient with ischemic stroke at this hospital. IV alteplase converts plasminogen to plasmin, which in turn breaks down fibrin and fibrinogen, thereby dissolving thrombus.
Question:What is the date that IV alteplase 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 IV alteplase 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 alteplase 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 alteplase initiation date was 03-42-20xx. No other documentation in the medical record provides a valid date. Since the IV alteplase 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 Alteplase 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 Alteplase Initiation Date
Specifications Manual for Joint Commission National Quality Measures (v2018B1)
Discharges 01-01-19 (1Q19) through 06-30-19 (2Q19)