Specifications Manual for Joint Commission National Quality Measures (v2018B1)
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Release Notes:
Data Element
Version 2018B1

Name:IV Alteplase Initiation Time
Collected For: ASR-IP-1, ASR-OP-1, CSTK-05, STK-4
Definition:The time for which IV alteplase was initiated at this hospital.
Question:What was the time of initiation for IV alteplase?
Length:5 - HH-MM (with or without colon) or UTD
Allowable Values:

HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to Determine

Time must be recorded in military time format. With the exception of Midnight and Noon:
  • If the time is in the a.m., conversion is not required
  • If the time is in the p.m., add 12 to the clock time hour


Midnight = 00:00
Noon = 12:00
5:31 am = 05:31
5:31 pm = 17:31
11:59 am = 11:59
11:59 pm = 23:59

00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the IV Alteplase Initiation Date should remain 11-24-20xx or if it should be converted to 11-25-20xx.

When converting Midnight or 24:00 to 00:00, do not forget to change the IV Alteplase Initiation Date.
Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx
Notes for Abstraction:
  • Use the time at which initiation of IV alteplase was first documented. If a discrepancy exists in time documentation from different sources, choose nursing documentation first before other sources. If multiple times are documented by the same individual, use the earliest time recorded by that person.
  • For times that include “seconds”, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00
  • The use of “hang time” or “infusion time” is acceptable as IV alteplase initiation time when other documentation cannot be found.
  • IV alteplase initiation time refers to the time the thrombolytic bolus/infusion was started.
  • Do not use physician orders unless there is documentation with the order that it was administered.
  • If the time of IV alteplase initiation 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 time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select “UTD”."
    Documentation indicates the IV alteplase initiation time was 3300. No other documentation in the medical record provides a valid time. Since the IV alteplase initiation time is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD”."
    Note: Transmission of a case with an invalid time 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 Time 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 Time
Specifications Manual for Joint Commission National Quality Measures (v2018B1)
Discharges 01-01-19 (1Q19) through 06-30-19 (2Q19)