Specifications Manual for Joint Commission National Quality Measures (v2020A)
Posted: August 1, 2019
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)
Home » Reason for Not Initiating Antenatal Steroids

Release Notes:
Data Element
Version 2020A

Name:Reason for Not Initiating Antenatal Steroids
Collected For: PC-03
Definition:Reasons for not initiating antenatal steroids before delivery are clearly documented in the medical record. Reasons for not initiating antenatal steroids may include fetal distress, imminent delivery or other reasons documented by physician/advanced practice nurse (APN)/physician assistant (PA)/certified nurse midwife (CNM).

Initial antenatal steroids are 12mg betamethasone IM or 6mg dexamethasone IM.

Question:Is there documentation in the medical record of reasons for not initiating antenatal steroids before delivery?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes) There is documentation by physician/APN/PA/CNM that the patient has one or more reasons for not initiating antenatal steroids before delivery.

N (No) There is no documentation by physician/APN/PA/CNM of a reason for not initiating antenatal steroids before delivery or unable to determine from medical record documentation.
Notes for Abstraction:When determining whether there is a reason documented by a physician/APN/PA or CNM for not initiating antenatal steroids, reasons must be explicitly documented (e.g., "patient had an adverse reaction to the medication in the past - unable to initiate antenatal steroids") or clearly implied (i.e., there is documentation of an imminent delivery which occurs within 2 hours after admission to the hospital, there is documentation the fetus has anomalies which are not compatible with life, there is documentation that the patient has chorioamnionitis).
Suggested Data Sources: PHYSICIAN/APN/PA/CNM DOCUMENTATION ONLY
  • History and physical
  • Physician progress notes
  • Prenatal forms
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Reason for Not Initiating Antenatal Steroids
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Specifications Manual for Joint Commission National Quality Measures (v2020A)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)

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