Reason for Not Administering a Procoagulant Reversal Agent (v2020A2)

Specifications Manual for Joint Commission National Quality Measures (v2020A2)

Posted: 10/30/2019

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Release Notes:
Data Element
Version 2020A2

Name:

Reason for Not Administering a Procoagulant Reversal Agent

Collected For:

CSTK-04

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.

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?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

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.

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”.
If a procoagulant reversal agent was initiated at a transferring hospital and none given at this hospital because the repeat INR was < 1.4, select "Yes".
If the patient was not taking warfarin prior to hospital arrival and has no documented history of warfarin use, select "Yes".

Suggested Data Sources:

Consultation notes
Emergency department record
History and physical
Progress notes
Discharge summary

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
Patient/family refusal	None

Specifications Manual for Joint Commission National Quality Measures (v2020A2)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)

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