Specifications Manual for Joint Commission National Quality Measures (v2021B2)
Posted: 9/29/2021
Home » Appropriate Justification for Multiple Antipsychotic Medications

Release Notes:
Data Element
Version 2021B2

Name:Appropriate Justification for Multiple Antipsychotic Medications
Collected For: HBIPS-5
Definition:Documentation in the medical record of appropriate justification for discharging the patient on two or more routine antipsychotic medications.
Question:Is there documentation in the medical record of appropriate justification for the patient being discharged on two or more antipsychotic medications?
Allowable Values:

1    The medical record contains documentation of a history of a minimum of three failed multiple trials of monotherapy.

2    The medical record contains documentation of a recommended plan to taper to monotherapy due to previous use of multiple antipsychotic medications OR documentation of a cross-taper in progress at the time of discharge.

3    The medical record contains documentation of augmentation of Clozapine.

4    The medical record contains documentation of a justification other than those listed in Allowable Values 1-3.

5    The medical record does not contain documentation supporting the reason for being discharged on two or more antipsychotic medications OR unable to determine from medical record documentation.
Notes for Abstraction:If the patient was in an acute-care hospital and had multiple admissions to the psychiatric unit during his or her hospitalization, this information should be abstracted only once at the time of discharge from the hospital or at the time of final discharge from the psychiatric unit.

"Failed multiple trials of monotherapy" comprises a history of three or more failed trials of monotherapy in which there was a lack of sufficient improvement in symptoms or functioning.
  • The trials could have been conducted with three different medications in which the documentation must include at a minimum the names of the antipsychotic medications that previously failed.
  • There could have been multiple trials with the same medication but different doses and timing of administration, in which case the documentation should include the names of the medication and a statement that the trials failed with different dosing and/or timing.

A cross-taper plan is defined as a plan to decrease the dosage of one or more antipsychotic medications while increasing the dosage of another antipsychotic medication to a level which results in controlling the patient's symptoms with one antipsychotic medication.

Both the recommended plan to taper to monotherapy and the cross-taper plan must include the name(s) of the medication(s) to be tapered.

Only allowable values 1, 2 and 3 are supported by an evidence base which will allow the case to pass the measure. Allowable value 4 can be used as part of an internal performance improvement activity, but the case will not pass the measure.
Suggested Data Sources:
  • Aftercare discharge plan
  • Discharge plan
  • Final discharge summary
  • History and physical
  • Interim discharge summary
  • Medication reconciliation form
  • Physician discharge orders
  • Physician progress notes
  • Referral form
Additional Notes:

Guidelines for Abstraction:
Inclusion Exclusion
  • None
  • None

Appropriate Justification for Multiple Antipsychotic Medications
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Specifications Manual for Joint Commission National Quality Measures (v2021B2)
Discharges 10-1-21 through 12-31-21 (4Q21)


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