Release Notes:
Data Element
Version 2018B1
| Name: | Reason for Not Prescribing Antithrombotic Therapy at Discharge |
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| Collected For: |
ASR-IP-3, STK-2 |
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| Definition: | Reason for not prescribing antithrombotic therapy at hospital discharge.
- Other reason documented by physician/APN/PA or pharmacist
Antithrombotic therapy is administered to reduce morbidity, mortality, and recurrence rate in stroke.
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| 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 antithrombotic therapy at hospital discharge? |
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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 prescribing antithrombotic therapy at hospital discharge.
N (No) There is no documentation of a reason for not prescribing antithrombotic therapy at hospital discharge, OR unable to determine from the medical record documentation.
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| Notes for Abstraction: |
- Reasons for not prescribing antithrombotic therapy at hospital discharge must be documented by a physician/APN/PA or pharmacist with one exception: Patient/family refusal of any form of antithrombotic therapy (e.g., “ASA refused,” “Patient refusing antithrombotic therapy”) may be documented by a nurse. .
- If reasons are not mentioned in the context of antithrombotics, do not make inferences (e.g., do not assume that antithrombotic therapy was not prescribed because of a bleeding disorder unless documentation explicitly states so).
- Reasons must be explicitly documented (e.g., “Active GI bleed – antithrombotic therapy contraindicated,” “H/O bleeding disorder – anticoagulation therapy contraindicated,” “Low platelet count – do not give antiplatelet medications,” “No ASA” [no reason given]).
- Consider the terms "anticoagulant", "antiplatelet", and "blood thinners" synonymous with antithrombotic therapy. Physician/APN/PA or pharmacist documentation, (e.g., "no blood thinners", "no anticoagulant medications", "no antiplatelet medications"), select "Yes".
- Documentation of "do not continue" or “do not convert” a home antithrombotic medication to an inpatient medication, or an inpatient antithrombotic medication to a discharge medication, does not count as a reason for not prescribing antithrombotic therapy at discharge. Do not infer that an antithrombotic medication was not prescribed or discontinued without explicit documentation of a reason for not prescribing an antithrombotic medication at discharge.
Example:
Patient on Plavix 75 mg daily while an inpatient. During discharge medication reconciliation, physician checks “do not convert” box next to Plavix, select “No.”
- Deferral of antithrombotic therapy from one physician/APN/PA or pharmacist to another does NOT count as a reason for not prescribing antithrombotic 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 ASA if OK with gastroenterology.” - select “Yes.”
- If there is documentation of a plan to initiate/restart antithrombotic therapy, and the reason/problem underlying the delay in starting/restarting antithrombotic therapy is also noted, this constitutes a “clearly implied” reason for not prescribing antithrombotic therapy at discharge.
Acceptable examples (select “Yes”):
- “Stool Occult Blood positive.
- May start Coumadin as outpatient.”
- “Start ASA if hematuria subsides.”
Unacceptable examples (select “No”):
- “Consider starting Coumadin in a.m.”
- “May add Plavix 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 ASA due to rectal bleeding” - select “Yes,” even if documentation indicates that the rectal bleeding has resolved by the time of discharge and ASA was restarted).
- An allergy or adverse reaction to one type of antithrombotic would NOT be a reason for not administering all antithrombotics. 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 ASA" documented in a transferring record.
- For patients prescribed ticagrelor as antithrombotic therapy at discharge due to a history of acute coronary syndrome (ACS), NSTE-ACS treated with early invasive strategy and/or coronary stenting, or other indications, select “Yes.”
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| Suggested Data Sources: |
ONLY PHYSICIAN/APN/PA OR PHARMACIST DOCUMENTATION OF A REASON FOR NOT PRESCRIBING ANTITHROMBOTIC THERAPY AT HOSPITAL DISCHARGE:
- Consultation notes
- Discharge summary
- After Visit Summary (AVS)
- Emergency Department record
- History and physical
- Medication administration record
- Medication reconciliation form
- Physician orders
- Progress Notes
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: |
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| Inclusion |
Exclusion |
None
Refer to Appendix C, Table 8.2 for a comprehensive list of Antithrombotic Medications.
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Antithrombotic 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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