Release Notes:
Data Element
Version 2018B1
| Name: | Reason for Not Administering a Procoagulant Reversal Agent |
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| Collected For: |
CSTK-04 |
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| Definition: | Reason for not administering a procoagulant reversal agent.
- Adverse reaction to a procoagulant reversal agent
- Other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist.
Procoagulant reversal agents are medications that increase coagulation factors to promote clotting. |
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| Question: | Is there documentation by a physician/APN/PA or pharmacist in the medical record of a reason for not administering a procoagulant reversal agent? |
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| Format: |
| Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
Y (Yes) There is documentation of a reason for not administering a procoagulant reversal agent.
N (No) There is no documentation of a reason for not administering a procoagulant reversal agent OR unable to determine from medical record documentation.
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| Notes for Abstraction: |
- Reasons for not administering a procoagulant reversal agent must be documented by the physician/APN/PA or pharmacist.
- If reasons are not mentioned in the context of a procoagulant reversal agent, do not make inferences (e.g., do not assume that a procoagulant reversal agent was not administered because of an adverse reaction to a procoagulant reversal agent unless documentation explicitly states so.)
- Reasons must be explicitly documented (e.g., “Allergic to cow milk. Do not give NovoSeven.
- Physician/APN/PA or pharmacist documentation of a hold on a procoagulant reversal agent or discontinuation of a procoagulant reversal agent constitutes a “clearly implied” reason for not administering the procoagulant reversal agent.
- When conflicting information is documented in the medical record, select “Yes”.
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| Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Progress notes
- Discharge summary
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| Additional Notes: |
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| Guidelines for Abstraction: |
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