Reason for Not Prescribing a High-Intensity Statin (v2022B2)

Specifications Manual for Joint Commission National Quality Measures (v2022B2)

Posted: 09/06/2022

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Release Notes:
Data Element
Version 2022B2

Name:

Reason for Not Prescribing a High-Intensity Statin

Collected For:

CCCIP-01

Definition:

Documentation of a reason for not prescribing a high-intensity statin at hospital discharge by a physician/APN/PA or pharmacist.

Question:

Did a physician/APN/PA or pharmacist document a contraindication to or a reason for not prescribing a high-intensity statin at hospital discharge?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) There is documentation by a physician/APN/PA or pharmacist of a contraindication to or a reason for not prescribing a high-intensity statin at hospital discharge.

N (No) There is no documentation by a physician/APN/PA or pharmacist of a contraindication to or a reason for not prescribing a high-intensity statin at hospital discharge or unable to determine from medical record documentation.

Notes for Abstraction:

Reasons that precludes prescribing a high-intensity statin must be documented by a physician/APN/PA/or pharmacist.
If the patient refuses a prescription for a high-intensity statin select 'Yes'.
Reasons for not prescribing a high-intensity statin must be explicitly documented or clearly implied.
- Physician/APN/PA or pharmacist documentation of a hold of a high-intensity statin or discontinuation of a high-intensity statin constitutes a “clearly implied” reason for not prescribing a high-intensity statin at hospital discharge.
- A hold/discontinuation of all p.o. medications counts if the high-intensity statin was on order at the time of the notation.
- If there is documentation of a plan to initiate/restart a high-intensity statin and the reason/problem underlying the delay in starting/restarting the high-intensity statin is also noted, this constitutes a “clearly implied” reason for not prescribing a high-intensity statin at discharge.
- Documentation of a conditional hold/discontinuation of a high-intensity statin does NOT count as a reason for NOT prescribing a high-intensity statin.
- Deferral of prescribing a high-intensity statin from one physician/APN/PA or pharmacist to another does NOT count as a reason for not prescribing a high-intensity statin, unless the problem underlying the deferral is also noted.
A statin “allergy” or “sensitivity” documented in the medical record counts as an allergy regardless of what type of reaction might be noted.
- Documentation of an allergy/sensitivity to one particular statin is acceptable to take as an allergy to the entire class of statin medications.

Suggested Data Sources:

Consultation notes
History and physical
Progress notes
Physician's notes
Discharge summary
ICU notes
Inpatient medical record

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion

Specifications Manual for Joint Commission National Quality Measures (v2022B2)
Discharges 10-01-22 through 12-31-22 (4Q22)

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