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Release Notes:
Data Element
Version 2010A1

Data Element Name: Antithrombotic Therapy Prescribed at Discharge
Collected For: ,
Definition:Documentation demonstrates that antithrombotic therapy was prescribed at discharge
Suggested Data Collection Question:Was antithrombotic therapy prescribed at discharge?
Allowable Values:

Y     (Yes, antithrombotic therapy was prescribed at discharge)

N    (No, antithrombotic therapy was not prescribed at discharge OR unable to determine from medical record documentation)

NC    (No, antithrombotic therapy was not prescribed at discharge. A documented reason exists for not administering this therapy)

Notes for Abstraction:
Antithrombotic Therapy:
Aspirin (ASA)
ASA/dipyridamole (Aggrenox) (bid)
warfarin (Coumadin)
clopidogrel (Plavix)
ticlopidine (Ticlid)
Unfractionated heparin IV
Full dose LMW heparin

Prescribed at discharge: Documentation that patient/caregiver was given a prescription for antithrombotic therapy at time of hospital discharge.

Reasons for not prescribing antithrombotic therapy must be documented by a physician, nurse practitioner or physician assistant. If reasons are not mentioned in the context of antithrombotics, do not make inferences (e.g., do not assume that antrithombotics are not being prescribed because of a bleeding disorder unless documentation explicitly states so.)

Conditions or factors making the administration of antithrombotic therapy inadvisable, inappropriate and/or undesirable are documented (appropriate response is “NC”, documented reason for not prescribing antithrombotic) This may include:

  • Allergy to or complication r/t antithrombotic (hx/current)
  • Aortic dissection (current)
  • Bleeding disorder
  • Brain/CNS cancer (hx/current)
  • CVA, hemorrhagic (hx/current)
  • Extensive/metastatic CA (hx/current)
  • Hemorrhage, any type (hx/current)
  • Intracranial surgery/biopsy (current)
  • Patient refusal
  • Peptic ulcer (current)
  • Planned surgery within 7 days following discharge
  • Risk of bleeding (current)
  • Unrepaired intracranial aneurysm (hx/current)
  • Other (patient/physician)
Suggested Data Sources:
  • Progress notes
  • Physician orders
  • Discharge summary
  • Medication record
  • Clinical logs
  • Discharge instructions
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • None
  • None

Antithrombotic Therapy Prescribed at Discharge
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)