Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020
Home » Reason for No Tobacco Cessation Medication During the Hospital Stay

Release Notes:
Data Element
Version 2020B

Name:Reason for No Tobacco Cessation Medication During the Hospital Stay
Collected For: TOB-2
Definition:Reasons for not administering an FDA-approved tobacco cessation medication documented during the patient's hospital stay include:
  • Allergy to all of the FDA-approved tobacco cessation medications
  • Drug interaction (for all of the FDA-approved medications) with other drugs the patient is currently taking
  • Patient is pregnant.
  • Other reasons documented by physician, advanced practice nurse(APN), physician assistant (PA), or pharmacist

Question:Is there documentation of a reason for not administering one of the FDA-approved tobacco cessation medications during the hospital stay?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes)    There is documentation of a reason for not administering an FDA-approved cessation medication during the hospital stay

N (No)    There is no documentation of a reason for not administering an FDA-approved cessation medication during the hospital stay or unable to determine from medical record documentation.
Notes for Abstraction:
  • Reasons (other than pregnancy) for not administering FDA-approved tobacco cessation medications must be documented by a physician/APN/PA or pharmacist.
  • If there is any documentation in the medical record indicating the patient is pregnant, select “Yes.”
  • An allergy or adverse reaction to one of the FDA-approved cessation medications would not be a reason for not administering another of the cessation medications.
  • In determining whether there is a reason documented by physican/APN/PA or pharmacist for not administering tobacco cessation medications, the reason must be explicitly documented (e.g., “No tobacco cessation medication as patient is post-operative and nicotine may place them at risk for impaired wound healing”) or clearly implied (e.g., “Patient becomes anxious when they take tobacco cessation medication”). If reasons are not mentioned in the context of cessation medication, do not make inferences (e.g., Do not assume that a tobacco cessation medication is not being prescribed because of the patient's history of recent surgery alone).
  • When conflicting information is documented in the medical record, select value ""No" for the indicated reasons present for not administering the tobacco cessation medications.
  • Documentation by the physician, advanced practice nurse (APN), physician assistant (PA), or pharmacist that the patient refused tobacco cessation medication is not considered a valid reason for no tobacco cessation medication during the hospitalization. If refusal is documented as the reason, select Value “No.”
Suggested Data Sources:
  • Anesthesia record
  • Consultation notes
  • Emergency department record
  • History and physical
  • Progress notes
  • Physician orders
  • Discharge summary
  • Medication administration record (MAR)
  • Transfer Form
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Allergy or sensitivity
  • Refer to Appendix C, Table 9.1 for a list of FDA-approved tobacco cessation medications
  • Medication allergy using a negative modifier or qualifier (questionable, risk of, suspect, etc.)

Reason for No Tobacco Cessation Medication During the Hospital Stay
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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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