Specifications Manual for Joint Commission National Quality Measures (v2023B)
Posted: 02/03/2023
Home » Prescription for Tobacco Cessation Medication

Release Notes:
Data Element
Version 2023B

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?
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

Prescription for Tobacco Cessation Medication
CPT® only copyright 2023 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2023B)
Discharges 07-01-23 (3Q23) through 12-31-23 (4Q23)


CPT® only copyright 2023 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

You, your employees and agents are authorized to use CPT® only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. You acknowledge that the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT®.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT® for resale and/or license, transferring copies of CPT® to any party not bound by this Agreement, creating any modified or derivative work of CPT®, or making any commercial use of CPT®. License to use CPT® for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt.

U.S. Government Rights This product includes CPT® which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does not agree to license CPT® to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association reserves all rights to approve any license with any Federal agency.

Disclaimer of Warranties and Liabilities. CPT® is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the (AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “accept”.