Statin Medication Prescribed at Discharge (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:

Statin Medication Prescribed at Discharge

Collected For:

STK-6

Definition:

Documentation that a statin medication was prescribed or continued at hospital discharge. Statins are a class of pharmaceutical agents that modify LDL cholesterol by blocking the action of an enzyme in the liver which is needed to synthesize cholesterol thereby decreasing the level of cholesterol circulating in the blood.

Question:

Was a statin medication prescribed at discharge?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) Statin medication prescribed at discharge.

N (No) Statin medication not prescribed at discharge OR unable to determine from medical record documentation.

Notes for Abstraction:

If there is documentation in the medical record that a statin medication was prescribed at discharge, then select "Yes". Documentation that the patient should continue to take a statin medication that was administered during the hospital stay or taken prior to hospital admission (e.g., home medication) is also acceptable. At minimum, the name of the statin medication must be documented.
In determining whether a statin medication was prescribed at discharge, it is not uncommon to see conflicting documentation amongst different medical record sources. For example, the discharge summary may list a statin medication that is not included in any of the other discharge medication sources (e.g., discharge orders). All discharge medication documentation available in the chart should be reviewed and taken into account by the abstractor.
- In cases where there is a statin medication in one source that is not mentioned in other sources, it should be interpreted as a discharge medication (select "Yes") unless documentation elsewhere in the medical record suggests that it was NOT prescribed at discharge - Consider it a discharge medication in the absence of contradictory documentation.
- If documentation is contradictory (e.g., physician noted “d/c lovastatin” in the discharge orders, but lovastatin is listed in the discharge summary’s discharge medication list), or after careful examination of circumstances, context, timing, etc, documentation raises enough questions, the case should be deemed "unable to determine" (select "No").
- Consider documentation of a hold on a statin medication after discharge in one location and a listing of that statin medication as a discharge medication in another location as contradictory ONLY if the timeframe on the hold is not defined (e.g., “Hold lovastatin”). Examples of a hold with a defined timeframe include “Hold Vytorin x2 days” and “Hold lovastatin until ALT/AST normalize.”
- If a statin medication is NOT listed as a discharge medication, and there is only documentation of a hold or plan to delay initiation/restarting of a statin medication after discharge (e.g., “Hold Vytorin x2 days,” “Start statins as outpatient,” “Hold lovastatin”), select “No.”
- If two discharge summaries are included in the medical record, use the one with the latest date/time. If one or both are not dated or timed, and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Use the dictated date/time over transcribed date/time, file date/time, etc.
  Examples:
  - Two discharge summaries, one dictated 5/22 (day of discharge) and one dictated 5/27 - Use the 5/27 discharge summary.
  - Two discharge medication reconciliation forms, one not dated and one dated 4/24 (day of discharge) - Use both.
Disregard a statin medication documented only as a recommended medication for discharge (e.g., “Recommend sending patient home on lovastatin”). Documentation must be clearer that a statin was actually prescribed at discharge.
Disregard documentation of statin prescribed at discharge when noted only by medication class (e.g., “Statin Prescribed at Discharge: Yes” on a core measures form). The statin must be listed by name.

Suggested Data Sources:

Consultation notes
Progress notes
Physician orders
Discharge summary
Medication reconciliation form
After Visit Summary (AVS)

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
Refer to Appendix C, Table 8.1 for a comprehensive list of Statin Medications.	None

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

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