Specifications Manual for Joint Commission National Quality Measures (v2020B2)
Posted: 9/2/2020
Home » Reason for No VTE Prophylaxis – Hospital Admission

Release Notes:
Data Element
Version 2020B2

Name:Reason for No VTE Prophylaxis – Hospital Admission
Collected For: STK-1
Definition:Physician/APN/PA or pharmacist documentation why mechanical AND pharmacological VTE prophylaxis was not administered at hospital admission.
  • Explicit documentation of a contraindication to BOTH mechanical prophylaxis AND pharmacological prophylaxis is needed.
Question:Is there physician/APN/PA or pharmacist documentation why VTE prophylaxis was not administered at hospital admission?

Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes)     There is physician/APN/PA or pharmacist documentation why VTE prophylaxis was not administered at hospital admission.

N (No)     There is no physician/APN/PA or pharmacist documentation why VTE prophylaxis was not administered at hospital admission or unable to determine from medical record documentation.
Notes for Abstraction:
  • To select “Yes” for this data element, documentation must be dated from arrival to the day after hospital admission. Documentation written after arrival but prior to admission is acceptable.
  • Reasons for not prescribing mechanical and pharmacological VTE prophylaxis must be documented by a physician/APN/PA or pharmacist.
    EXCEPTIONS:
    • Patient/family refusal may be documented by a nurse, but should be documented within the same time frame as the reason for no VTE prophylaxis. Patient/family refusal of any form of prophylaxis is acceptable.
      Example:
      Patient refused heparin, select “Yes.”
  • For patients on anticoagulants:
    • For patients on continuous IV heparin therapy the day of or day after hospital admission, select “Yes.”
    • If warfarin is listed as a home or current medication, select “Yes” regardless of other documentation.
    • For patients receiving anticoagulant therapy for atrial fibrillation or for other conditions (e.g. angioplasty), with anticoagulation administered on the day of or the day after hospital admission, select “Yes.”
  • If reasons are not mentioned in the context of VTE prophylaxis, do not make inferences (e.g., do not assume that VTE Prophylaxis was not administered because of a bleeding disorder unless documentation explicitly states so).
    Example:
    Physician/APN/PA or pharmacist documentation of bleeding risk, review the chart for documentation about reasons for no mechanical AND reasons for no pharmacological VTE prophylaxis.
    EXCEPTION:
    • Documentation within the timeframe specified that the patient is a bilateral lower extremity amputee is an acceptable reason for no mechanical prophylaxis.
  • Physician/APN/PA or pharmacist documentation that the patient is ambulating without mention of VTE prophylaxis is insufficient. Do not infer that VTE prophylaxis is not needed unless explicitly documented.
    Examples:
    • There is documentation of “No VTE Prophylaxis, patient ambulating,” select “Yes.”
    • There is documentation of “Patient low risk for VTE, ambulating,” select “Yes.”
  • For patients with a reason for no pharmacologic or no mechanical prophylaxis and an order for ANY prophylaxis that was NOT administered without a reason, select “No.”
    Example:
    • Patient has documentation of an order for IPCs and no documentation that IPCs were applied, select “No.”
  • If two physicians/APN/PA or pharmacists document conflicting or questionable risk/ needs for prophylaxis, select “No.”
  • If a risk assessment is used, and notes anything other than low risk (e.g. intermediate risk, moderate risk, or high risk), additional documentation must be present to answer “Yes.” Explicit documentation of a contraindication to mechanical AND contraindication to pharmacological prophylaxis must be addressed.
    • If there is physician documentation of “bleeding, no pharmacologic prophylaxis” the chart must be reviewed for documentation about a reason for no mechanical prophylaxis in order to select “Yes.”
      Examples:
      • Bleeding, no pharmacologic prophylaxis, no mechanical prophylaxis.
      • Active GI bleed – low molecular weight heparin contraindicated, no mechanical prophylaxis needed.
      • "No VTE Prophylaxis", "No VTE Prophylaxis needed" [no reason given].
  • Documentation that the patient is adequately anticoagulated or already anticoagulated on warfarin, select “Yes.”
    Examples:
    • Patient is already anticoagulated, taking Coumadin at home prior to admission.
    • INR therapeutic and adequately anticoagulated at this time.
  • Documentation synonymous with “abruptly reversed anticoagulation for major bleeding,” select “Yes.”
    Examples:
    • INR reversal for major bleeding.
    • Reverse anticoagulation for intracranial hemorrhage.
  • Documentation of administration of IV alteplase / tPA is NOT a stand-alone reason for no VTE prophylaxis.
  • Graduated compression stockings (GCS) are not sufficient VTE prophylaxis for stroke patients. If GCS only were applied on the day of or day after hospital admission and no other form of prophylaxis administered, then a reason for no pharmacological prophylaxis and a reason for no mechanical prophylaxis must be documented in the medical record.

Suggested Data Sources: ONLY PHYSICIAN/APN/PA OR PHARMACIST DOCUMENTATION OF A REASON FOR NOT ADMINISTERING VTE PROPHYLAXIS:
  • Consultation notes
  • Emergency Department record
  • History and physical
  • Physician orders
  • Physician progress notes
  • Risk assessment form
  • Transfer form
  • Medication administration record
  • Nurses notes
  • Risk Assessment

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None
Refer to Appendix H, Table 2.7 Anticoagulation Therapy for Atrial Fibrillation and Other Conditions.
  • Unchecked checkbox next to a reason (e.g., blank checkbox on a form or electronic template next to “cogulapathy” or "bilateral amputee").
  • Checked checkbox next to "other reason" with a blank space for the specific reason.

Reason for No VTE Prophylaxis – Hospital Admission
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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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