Reason for No Tobacco Cessation Medication at Discharge (v2023B)

Specifications Manual for Joint Commission National Quality Measures (v2023B)

Posted: 02/03/2023

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Release Notes:
Data Element
Version 2023B

Name:

Reason for No Tobacco Cessation Medication at Discharge

Collected For:

TOB-3

Definition:

Reasons for not administering an FDA-approved tobacco cessation medication at discharge include:

Allergy to all of the FDA-approved tobacco cessation medications.
Drug interaction (for all of the FDA-approved medications) with other drugs the patient is currently taking.
Patient is pregnant.
Other reasons documented by physician, advanced practice nurse(APN), physician assistant (PA), or pharmacist.

Question:

Is there documentation of a reason for not prescribing one of the FDA-approved tobacco cessation medications at discharge?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) There is documentation of a reason for not prescribing an FDA-approved cessation medication at discharge

N (No) There is no documentation of a reasons for not prescribing an FDA-approved cessation medication at discharge or Unable to Determine (UTD) from medical record documentation

Notes for Abstraction:

Reasons (other than pregnancy) for not prescribing FDA-approved tobacco cessation medications must be documented by a physician/APN/PA or pharmacist.
If there is any documentation in the medical record indicating the patient is pregnant, select “Yes.”
An allergy or adverse reaction to one of the FDA-approved cessation medications would not be a reason for not prescribing another of the cessation medications.
In determining whether there is a reason documented by physician/APN/PA or pharmacist for not prescribing tobacco cessation medications, the reason must be explicitly documented (e.g., “No tobacco cessation medication as patient is post-operative and nicotine may place them at risk for impaired wound healing”) or clearly implied (e.g., “Patient becomes anxious when they take tobacco cessation medication”). If reasons are not mentioned in the context of cessation medication, do not make inferences (e.g., Do not assume that a tobacco cessation medication is not being prescribed because of the patient's history of recent surgery alone).
When conflicting information is documented in the medical record, select Value “No.”
If the reason for not prescribing FDA-approved cessation medication is documented at any time during the hospitalization, additional documentation of the reason at the time of discharge is not required.
Documentation by the physician, advanced practice nurse (APN), physician assistant (PA), or pharmacist that the patient refused tobacco cessation medication is not considered a valid reason for no tobacco cessation medication at discharge. If refusal is documented as the reason, select Value “No.”

Suggested Data Sources:

Anesthesia record
Emergency department record
History and physical
Progress notes
Physician orders
Discharge summary
Medication administration record (MAR)
Consultation record
Transfer Form

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
Allergy or sensitivity Refer to Appendix C, Table 9.1 for a list of FDA-approved tobacco cessation medications	Medication allergy using a negative modifier or qualifier (questionable, risk of, suspect, etc.)

Specifications Manual for Joint Commission National Quality Measures (v2023B)
Discharges 07-01-23 (3Q23) through 12-31-23 (4Q23)

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