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Release Notes:
Data Element
Version 2010A1

Data Element Name: Contraindication to Relievers
Collected For: CAC-1, Joint Commission Only
Definition:Contraindications/reasons for not prescribing relievers during this hospitalization include: allergy to relievers, or other reasons documented by physician/APN/PA or pharmacist for not prescribing relievers during this hospitalization.

Relievers are medications that relax the bands of muscle surrounding the airways and are used to quickly alleviate bronchoconstriction and prevent exercise-induced bronchospasm. Relievers are also known as rescue, quick-relief, or short acting medications of choice to quickly relieve asthma exacerbations.

Suggested Data Collection Question:Is one or more of the following potential contraindications or reasons for not prescribing relievers documented?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y    (Yes)   There is documentation of one or more of the following potential contraindications/reasons for not prescribing relievers during this hospitalization:

  • Allergy to relievers
  • Other reasons documented by physician/APN/PA or pharmacist for not prescribing relievers during this hospitalization

N   (No)   There is no documentation of potential contraindications/reasons for not prescribing relievers during this hospitalization or unable to determine from medical record documentation.

Notes for Abstraction:
  • This data element should be answered independently and irrespective of whether the patient was prescribed relievers during this hospitalization
  • When there is documentation of an “allergy”, “sensitivity”, “intolerance”, “adverse or side effects”, cardiac dysrhythmias, etc., regard this as documentation of contraindication regardless of what type of reaction might be noted. Do not attempt to distinguish between true allergies, sensitivities, intolerances, adverse or side effects, cardiac dysrhythmias, etc. (e.g., “Allergies: Relievers – select “Yes.”)
  • The abstractor should search every suggested data source listed for the collection of information. When conflicting information is documented in a medical record, a positive finding should take precedence over a negative finding (e.g., answer “Yes”), unless otherwise specified.
  • When determining whether there is a reason documented by a physician/APN/PA or pharmacist for not prescribing relievers during this hospitalization:
    • Reasons must be explicitly documented or clearly implied (e.g., “intolerance to relievers” or “problems with relievers in past.”)
Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Nursing notes
  • Progress notes
  • Physician orders
  • Discharge summary
  • Medication administration record (MAR)
  • Medication reconciliation form
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Allergies/sensitivities/intolerance
  • Cardiovascular side effects
  • Cardiac dysrhythmias or arrhythmias
  • Side effects

Refer to Appendix C, Table 6.2 for a comprehensive list of Reliever Medications.

  • None

Contraindication to Relievers
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)