Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020
Home » Prescription for Tobacco Cessation Medication

Release Notes:
Data Element
Version 2020B

Name:Prescription for Tobacco Cessation Medication
Collected For: TOB-3
Definition:Documentation that an FDA-approved tobacco cessation medication was prescribed at hospital discharge.
Question:Was an FDA-approved tobacco cessation medication prescribed at discharge?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

1    A prescription for an FDA-approved tobacco cessation medication was given to the patient at discharge

2    A prescription for an FDA-approved cessation medication was offered at discharge and the patient refused

3    The patient:
- is being discharged to a residence outside the USA
- is released to a court hearing and does not return
- is being discharged to jail/law enforcement

4    A prescription for an FDA-approved cessation medication was not offered at discharge or Unable to Determine (UTD) from medical record documentation.

Notes for Abstraction:
  • All discharge medication documentation available in the chart should be reviewed and taken into account by the abstractor. In determining whether a tobacco cessation medication was prescribed at discharge, it is not uncommon to see conflicting documentation among different medical record sources. For example, the discharge summary may list Varenicline and this is not included in any of the other discharge medication sources (e.g., discharge orders). Select Value “1” unless documentation elsewhere in the medical record suggests that it (tobacco cessation medication) was not prescribed at discharge.
  • If documentation is contradictory (physician noted “d/c Varenicline” or “hold Varenicline” in the discharge orders, but Varenicline is listed in the discharge summary’s discharge medication list) or after careful examination of circumstance, context, timing, etc., the documentation remains unclear, the case should be deemed unable to determine. Select Value “4.”
  • If the physician wishes the patient to continue on medication that does not require a prescription (for example, over-the-counter nicotine replacement therapy (NRT) or medication that will be provided by the outpatient counseling or quit line), select Value “1” if the medication is listed on the discharge medication list.
  • If NRT or a prescribed FDA-approved tobacco cessation medication is listed as a discharge medication but there is also documentation of refusal by the patient at discharge, select Value “2.”
  • If the patient does not have a residence in the USA, Value “3” must be selected.
  • If the patient refused tobacco cessation medication during the hospitalization, a prescription must be offered again at the time of discharge. Select Value “4” if documentation reflects that a prescription for cessation medication was not offered at the time of discharge.
Suggested Data Sources:
  • Discharge summary
  • Transfer sheet
  • Discharge Instruction Sheet
  • Medication Reconciliation Form
  • Nursing Discharge notes
  • Physician Orders Sheet
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Refer to Appendix C, Table 9.1 for a comprehensive list of FDA-approved tobacco cessation medications
None

Prescription for Tobacco Cessation Medication
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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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