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Release Notes:
Data Element
Version 2010A1

Data Element Name: Contraindication to Systemic Corticosteroids
Collected For: CAC-2, Joint Commission Only
Definition:Contraindications/reasons for not prescribing systemic corticosteroids during this hospitalization include: allergy to systemic corticosteroids, oral or intravenous (systemic) corticosteroids were administered to the patient within 24 hours prior to arrival AND patient was not a candidate to receive an additional dose during this hospitalization, or other reasons documented by physician/APN/PA or pharmacist for not prescribing oral or intravenous (systemic) corticosteroids during this hospitalization.

Corticosteroids are a family of potent anti-inflammatory medications produced either naturally by the adrenal cortex or manufactured synthetically, in inhaled, topical, oral, and intravenous forms.

Suggested Data Collection Question:Is one or more of the following potential contraindications or reasons for not prescribing oral or intravenous (systemic) corticosteroids 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 oral or intravenous (systemic) corticosteroids during this hospitalization:

  • Allergy to corticosteroids
  • Oral or intravenous (systemic) corticosteroids were administered to the patient within 24 hours prior to arrival AND patient was not a candidate to receive an additional dose during this hospitalization.
  • Other reasons documented by physician/APN/PA or pharmacist for not prescribing oral or intravenous (systemic) corticosteroids during this hospitalization.

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

Notes for Abstraction:
  • This data element should be answered independently and irrespective of whether the patient was prescribed oral or intravenous (systemic) corticosteroids during this hospitalization.
  • When there is documentation of an “allergy”, “sensitivity”, “intolerance”, “adverse or side effects”, 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, etc. (e.g., “Allergies: Systemic Corticosteroids – 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 oral or intravenous (systemic) corticosteroids during this hospitalization:
    • Reasons must be explicitly documented or clearly implied (e.g., “intolerance to systemic corticosteroids” or “problems with systemic corticosteroids 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)
  • Ambulance record
  • Medication reconciliation form
  • Records from physician's office, clinic, or transferring facility (must be a part of this current medical record)
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • Allergies/sensitivities/intolerance
  • Side effects

Refer to Appendix C, Table 6.3 for a comprehensive list of Systemic Corticosteroids.

  • None

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