Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020
Home » Antithrombotic Therapy Administered by End of Hospital Day 2

Release Notes:
Data Element
Version 2020B

Name:Antithrombotic Therapy Administered by End of Hospital Day 2
Collected For: ASR-IP-2, STK-5
Definition:Documentation that antithrombotic therapy was administered by the end of hospital day 2. Antithrombotics include both anticoagulant and antiplatelet drugs.
Question:Was antithrombotic therapy administered by the end of hospital day 2?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes)     Antithrombotic therapy was administered by the end of hospital day 2.

N (No)     Antithrombotic therapy was not administered by the end of hospital day 2, OR unable to determine from medical record documentation.

Notes for Abstraction:
  • To compute end of hospital day 2, count the arrival date as hospital day 1. If antithrombotic therapy was administered by 11:59 p.m. of hospital day two, select “Yes” for this data element. Documentation of antithrombotic administration must be found within the timeframe of arrival to the end of hospital day 2. It is not necessary to review documentation outside of this timeframe to answer this data element.
  • For antithrombotic therapy administered in the Emergency Department/observation area prior to the end of hospital day 2, select “Yes.”
  • Antithrombotic therapy administration information must demonstrate actual administration of the medication.
    Example:
    Do not use physician orders as they do not demonstrate administration of the antithrombotic therapy (in the ED this may be used if signed/initialed by a nurse).
  • When antithrombotic is noted as a “home” or “current” medication or documentation indicates that it was received prior to hospital arrival only, select “No.”
  • Lovenox SQ for VTE prophylaxis (i.e. enoxaparin SQ 40 mg once daily; enoxaparin SQ 30 mg Q12 hours) is not sufficient. If no other antithrombotic therapy is administered by the end of hospital day 2, select “No.”
Suggested Data Sources:
  • Emergency department record
  • Nursing notes
  • Nursing flow sheet
  • Progress notes
  • Physician orders
  • Medication administration record (MAR)
Excluded Data Sources
  • Emergency medical system (EMS) or ambulance documentation.
  • Any documentation dated/timed prior to hospital arrival or after hospital day 2.
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Refer to Appendix C, Table 8.2 for a list of medications used for antithrombotic therapy.
  • Heparin Flush
  • Heparin SQ
  • Hep-Lock

Antithrombotic Therapy Administered by End of Hospital Day 2
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Specifications Manual for Joint Commission National Quality Measures (v2020B)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

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