Release Notes:
Data Element
Version 2010A1
| Data Element Name: | Discharge Instructions Address Medications |
|---|
| Collected For: | HF-1, |
|---|
| Definition: | Written discharge instructions or other documentation of educational material given to patient/caregiver addressing all discharge medications. Instructions must address at least the names of all discharge medications but may also include other usage instructions such as dosages, frequencies, side effects, etc.
|
|---|
| Suggested Data Collection Question: | Did the WRITTEN discharge instructions or other documentation of educational material given to the patient/caregiver address all discharge medications? |
|---|
| Format: | | Length: | 1 |
|---|
| Type: | Alphanumeric |
|---|
| Occurs: | 1 |
|---|
|
|---|
| Allowable Values: |
Y (Yes) WRITTEN discharge instructions/educational material given to patient/caregiver address discharge medications.
N (No) WRITTEN discharge instructions/educational material do not address all discharge medications or unable to determine from medical record documentation.
JOINT COMMISSION NOTE TO PROGRAMMERS:
In order to identify the specific discharge instructions that are missing, the internal variables (discharge counter and missing flag) must be stored so calculations of rates for each instruction component can be performed.
|
|---|
| Notes for Abstraction: |
- Instructions must address at least the NAMES of all discharge medications.
- In addition to names of medications, instructions may include other usage instructions such as dosages, frequencies, side effects, etc. These types of instructions are NOT required.
- Abstraction is a two-step process:
- Determine all of the medications being prescribed at discharge, based on available medical record documentation.
-Discharge medication information included in a discharge summary dated after discharge should be used as long as it was added during the hospital’s normal course of completing a medical record per organization policy, or within 30 days after discharge, whichever is sooner.
-If discharge medications are noted using only references such as “continue home meds,” “resume other meds,” or “same medications,” rather than lists of the names of the discharge medications, the abstractor should use all sources to compile a list of medications the patient was on prior to arrival (or in the case of transfers from acute care hospitals, the medications the patient was on prior to arrival at the first acute care hospital).
-Disregard all references to laxatives, antacids, vitamins, minerals, food supplements, and herbs, prn or not, AND disregard references to medications by class only (e.g., “calcium channel blocker”) where the specific medication name is not specified. They are NOT required in the written instructions for the purposes of the Discharge Instructions measure (HF-1).
-PRN medications are required on the discharge instructions, with ONE exception: When discharge medications outside of the written discharge instructions are noted using ONLY references such as “continue current medications” or “continue present meds,” rather than lists of the names of the discharge medications, and the abstractor is referencing what medications the patient was taking on the day of discharge (for comparison against the written discharge instructions, to confirm completeness of that list), medications which are clearly listed as prn (given on an as needed basis only) do NOT need to be included in the written discharge instructions.
-Oxygen should not be considered a medication.
-Medications which the patient will not be taking at home (and/or the caregiver will not be giving at home) are NOT required in the medication list included in the written discharge instructions (e.g., monthly B12 injections, intermittent IV dobutamine, Natrecor infusions, dialysis meds, chemotherapy).
- Check this list against the written discharge instructions given to the patient to ensure that these instructions addressed at least the names of all of the discharge medications. If a list of discharge medications is not documented elsewhere in the record, and the completeness of the medication list in the written discharge instructions cannot be confirmed as complete, or it can be determined to be incomplete, select “No.”
- EXCEPTION:
-If a comparison list is not available, and the discharge list in the written discharge instructions cannot be determined to be complete or incomplete, but the written discharge instructions given to the patient have the name or initials of the physician/advanced practice nurse/physician assistant (physician/APN/PA) signed on the form, presume the list of discharge medications in those instructions is complete.
- In making medication name comparisons, consider two medications that are brand/trade name vs. generic name in nature or that have the same generic equivalent as matches.
Examples of matches:
-Vasotec vs. enalapril
-Toprol vs. Toprol XL
-ASA vs. EC ASA
-Prinivil vs. Zestril
-Lopressor vs. metoprolol
-Metoprolol vs. metoprolol succinate
Examples of mismatches:
-Lopressor vs. Toprol (metoprolol tartrate vs. metoprolol succinate)
-Prevacid vs. Protonix (lansoprazole vs. pantoprazole sodium)
- If there is documentation that the patient was discharged on insulin(s) of ANY kind, ANY reference to ANY type of insulin in the written discharge instructions is sufficient, for the purposes of the Discharge Instructions measure (HF-1). E.g., Dc summary notes patient discharged on “Humulin Insulin” and “Insulin 70/30” is listed on the discharge instruction sheet – Consider this a match.
- In determining the medications prescribed at discharge (step 1 above), it is not uncommon to see conflicting documentation amongst different medical record sources. For example, the discharge summary may list a discharge medication that is not included in any of the other discharge medication sources (e.g., discharge orders). All discharge medication documentation available in the chart should be reviewed and taken into account by the abstractor.
- In cases where there is a medication in one source that is not mentioned in other sources, it should be interpreted as a discharge medication (i.e., required in the written discharge instructions) unless documentation elsewhere in the medical record suggests that it was NOT prescribed at discharge - Consider it a discharge medication in the absence of contradictory documentation.
- If documentation is contradictory (e.g., physician/APN/PA noted discontinuation of a particular medication in the discharge medication orders, but this medication is listed in the discharge summary’s discharge medication list), or, after careful examination of circumstances, context, timing, etc, documentation raises enough questions about what medications are being prescribed at discharge, the case should be deemed "unable to determine” (select "No”), regardless of whether the medication in question is included in the discharge medication list in the written discharge instructions.
-In cases in which there was a therapeutic substitution of a home medication (e.g., per hospital formulary Protonix substituted for Prilosec) and it is not clear which medication the patient is being discharged on, or there is contradictory documentation regarding which medication is prescribed at discharge, select "No” regardless of which medication is included in the discharge medication list in the written discharge instructions.
- If a medication is listed as a discharge medication, it should be interpreted as such (i.e., required in the written discharge instructions), unless contradictory documentation exists (see above). If a medication is not listed as a discharge medication, and there is only documentation of a plan to delay initiation/restarting of the medication for a time period after discharge, do not regard it as a discharge medication.
- Cases where the patient was given written discharge medication instructions only in the form of written prescriptions do not fulfill the intent of this measure. Such cases should NOT receive medication instruction credit.
- Some hospitals use discharge instruction sheets, brochures, booklets, and teaching sheets to provide written instructions to the patient. Others use electronically formatted media such as videos, CDs, and DVDs, which are also acceptable educational materials.
- Documentation must clearly convey that the patient was given a copy of the discharge instruction material to take home. When a discharge instruction sheet, teaching sheet, brochure, or booklet is present in the medical record and there is no documentation which clearly suggests that a copy was given to the patient/caregiver (e.g., statement on form such as “pink copy to patient”), the inference should be made that it was given IF the patient's name or the medical record number appears on the material AND hospital staff or the patient/caregiver has signed the material.
- When a copy of the material is not included in the medical record, documentation must clearly show that the names of all medications prescribed at discharge are included in the material. Use only the documentation provided in the medical record itself. If material is located outside of the medical record, it should not be reviewed and used in abstraction.
- Documentation of medication instructions in the educational material can take many forms.
Examples:
-Discharge nursing note which outlines the areas covered in the material such as "Heart Failure Management brochure given to pt. - addresses diet, activity, and medications – Lasix, Vasotec, and Aspirin"
-Copy of medication table from booklet (with names of the patient’s discharge medications filled in) included in medical record
- Written instructions do NOT need to be given at the time of discharge. Instructions given anytime during the hospital stay are acceptable.
- If the patient refused written discharge instructions or other documentation of educational material which addressed discharge medications, select “Yes.”
- The caregiver is defined as the patient’s family or any other person (e.g., home health/VNA provider) who will be responsible for care of the patient after discharge.
|
|---|
| Suggested Data Sources: |
- Discharge summary
- Care plans/clinical pathway
- Discharge instruction sheet
- Discharge progress notes
- Home health referral form
- Medication reconciliation form
- Nursing discharge notes
- Teaching sheet
|
|---|
| Additional Notes: |
|
|---|
| Guidelines for Abstraction: |
|---|
| Inclusion | Exclusion | |
|
- Any general reference to a medication regimen (e.g., “continue home meds,” “Same” or “see MAR” listed in medication section of discharge instruction sheet), without specific documentation of medication names
|
|
Discharge Instructions Address Medications
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
|
|
|
| | |
|