Specifications Manual for Joint Commission National Quality Measures (v2020B2)
Posted: 9/2/2020
Home » Reason for Not Administering a Procoagulant Reversal Agent

Release Notes:
Data Element
Version 2020B2

Name:Reason for Not Administering a Procoagulant Reversal Agent
Collected For: CSTK-04
Definition:Reason for not administering a procoagulant reversal agent.
  • Adverse reaction to a procoagulant reversal agent
  • Other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist.

Procoagulant reversal agents are medications that increase coagulation factors to promote clotting.
Question:Is there documentation by a physician/APN/PA or pharmacist in the medical record of a reason for not administering a procoagulant reversal agent?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes) There is documentation of a reason for not administering a procoagulant reversal agent.

N (No) There is no documentation of a reason for not administering a procoagulant reversal agent OR unable to determine from medical record documentation.
Notes for Abstraction:
  • Reasons for not administering a procoagulant reversal agent must be documented by the physician/APN/PA or pharmacist.
  • If reasons are not mentioned in the context of a procoagulant reversal agent, do not make inferences (e.g., do not assume that a procoagulant reversal agent was not administered because of an adverse reaction to a procoagulant reversal agent unless documentation explicitly states so.)
    • Reasons must be explicitly documented (e.g., “Allergic to cow milk. Do not give NovoSeven.
    • Physician/APN/PA or pharmacist documentation of a hold on a procoagulant reversal agent or discontinuation of a procoagulant reversal agent constitutes a “clearly implied” reason for not administering the procoagulant reversal agent.
  • When conflicting information is documented in the medical record, select “Yes”.
  • If a procoagulant reversal agent was initiated at a transferring hospital and none given at this hospital because the repeat INR was < 1.4, select "Yes".
  • If the patient was not taking warfarin prior to hospital arrival and has no documented history of warfarin use, select "Yes".
Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Progress notes
  • Discharge summary
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Patient/family refusal
None

Reason for Not Administering a Procoagulant Reversal Agent
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Specifications Manual for Joint Commission National Quality Measures (v2020B2)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

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