• In determining whether there is a reason documented by physician/APN/PA for not doing LDL-c testing:
  • Reasons must be explicitly documented (e.g., “ESRD, life expectancy < 1 month - Will not do LDL: HDL”) or clearly implied (e.g., “Patient refusing labs,” “Limited life expectancy, will not do any further evaluation,” “Lipid testing not indicated”). If reasons are not mentioned in the context of LDL-c testing, do not make inferences (e.g., do not assume that the physician/APN/PA is not doing LDL-c testing because the patient is of advanced age). If the physician/APN/PA documents that he is deferring the LDL-c testing to another physician/APN/PA, this should NOT count as a reason for not doing LDL-c testing unless the reason/problem underlying the deferral is also noted (e.g., Select "No" if “Consulting cardiologist to evaluate pt. for cholesterol testing” or "Pt. to follow up with physician/APN/PA re measuring lipids as outpatient").
  • When a physician/APN/PA documents a reason for not doing lipid testing (e.g., “On Lipitor, Chol. testing not needed at this time”), this should be construed as a reason for not doing LDL-c testing

PHYSICIAN/APN/PA DOCUMENTATION ONLY

• Consultation notes
• Discharge summary
• Emergency department record
• History and physical
• Progress notes

Excluded Data Sources:
Any documentation dated/timed after discharge, except discharge summary and operative/procedure/diagnostic test reports (from procedure done during hospital stay)