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Release Notes:
Data Element
Version 2010A1

Data Element Name: Fibrinolytic Administration Time
Collected For: AMI-7, AMI-7a,
Definition:The time (military time) that primary fibrinolytic therapy started. Fibrinolytic therapy is the administration of a pharmacological agent intended to cause lysis of a thrombus (destruction or dissolution of a blood clot).
Suggested Data Collection Question:What was the time primary fibrinolytic therapy was initiated during this hospital stay?
Length:5 - HH:MM (with or without colon) or UTD
Allowable Values:

HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to Determine

Time must be recorded in military time format.
With the exception of Midnight and Noon:

  • If the time is in the a.m., conversion is not required
  • If the time is in the p.m., add 12 to the clock time hour

Midnight = 00:00      Noon = 12:00
5:31 am = 05:31     5:31 pm = 17:31
11:59 am = 11:59    11:59 pm = 23:59

00:00 = midnight. If your electronic system documents time as 00:00 11-24-2007, review supporting documentation to determine if the Fibrinolytic Administration Date should remain 11-24-2007 or if it should be converted to 11-25-2007. When converting 24:00 to 00:00 do not forget to change the Fibrinolytic Administration Date.

Midnight or 24:00 on 11-24-2007 = 00:00 on 11-25-2007

Notes for Abstraction:
  • For times that include “seconds”, remove the seconds and record the time as is.
    15:00:35 would be recorded as 15:00
  • If the time primary fibrinolytic therapy was initiated is unable to be determined from medical record documentation, enter UTD.
  • The medical record must be abstracted as documented (taken at “face value”). When the time documented is obviously in error (not a valid time/format) and no other documentation is found that provides this information, the abstractor should select “UTD.”
    Documentation indicates the Fibrinolytic Administration Time was 3300. No other documentation in the medical record provides a valid time. Since the Fibrinolytic Administration Time is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD.”
    Transmission of a case with an invalid time as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse. Use of “UTD” for Fibrinolytic Administration Time allows the case to be accepted into the warehouse.
  • If there are two or more different fibrinolytic administration times (either different fibrinolytic episodes or corresponding with the same episode), enter the earliest time.
  • In the event the patient was brought to the hospital via ambulance and fibrinolytic therapy was infusing at the time of hospital arrival, enter the time the patient arrived at this hospital.
Suggested Data Sources:
  • Emergency department record
  • Nursing notes
  • Medication administration record (MAR)
  • Transfer sheet
  • Ambulance record
  • ICU/nursing flow sheets
  • IV flow sheets
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • None
  • Fibrinolytics given during or after a PCI

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