Reason for No Regional Anesthesia (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 No Regional Anesthesia

Collected For:

THKR-IP-1, THKR-OP-1

Definition:

Reasons why regional anesthesia was not used or attempted for the procedure:

Documentation of previous spinal fusion
Documentation of patient/family refusal of regional anesthesia
Other reasons why regional anesthesia was not used or attempted documented by physician/APN/PA

Question:

Is there physician/APN/PA documentation why regional anesthesia was not used or attempted for the procedure?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) There is physician/APN/PA documentation why regional anesthesia was not used or attempted.

N (No) There is no physician/APN/PA documentation why regional anesthesia was not used or attempted or unable to determine from medical record documentation.

Notes for Abstraction:

To select “Yes” for this data element, documentation of a reason for not using or attempting regional anesthesia must be dated prior to or on the PACU Discharge Date. If the patient did not go to the PACU, documentation must be dated prior to or on the day of surgery.
If reasons are not mentioned in the context of anesthesia, do not make inferences (e.g., do not assume that regional anesthesia was not used because of a bleeding disorder unless documentation explicitly states so).
Example:
- "Bleeding disorder”, review the chart for documentation about reason why regional anesthesia was not used or attempted. If no further documentation select “no”.
- “Recommend general anesthesia due to history of spinal fusion”, select “yes”.
“Other” reasons for not using or attempting regional anesthesia must be documented by a physician/APN/PA.
Exceptions to physician/APN/PA documentation of a reason for no regional anesthesia:
- Patient family refusal may be documented by a nurse, but must be dated prior to or on the PACU Discharge Date (or prior to or on the date of surgery if the patient did not go to the PACU). Patient/family refusal of any form of regional anesthesia is acceptable. Example: Patient refused spinal anesthesia, select “Yes.”
- Historical documentation present at the patient level in the electronic health record indicating the patient had a previous spinal fusion. As electronic data are available at all times during the encounter, it is acceptable to use this data for abstraction purposes.

Suggested Data Sources:

Anesthesia record
Operative notes
Procedure notes
PACU/recovery room record
Intraoperative Record

SUGGESTED DATA SOURCES FOR PATIENT/FAMILY REFUSAL (other than physician/APN/PA documentation):

Flowsheet
Nurses notes

Additional Notes:

Guidelines for Abstraction:

Inclusion

Exclusion

Patient Refusal
History of Spinal Fusion

None

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

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