Release Notes:
Data Element
Version 2010A1
| Data Element Name: | Cholesterol Reducing Therapy Prescribed at Discharge |
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| Collected For: | , |
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| Definition: | Documentation that a cholesterol reducing drug was prescribed at discharge. Cholesterol reducing drugs work by blocking the action of an enzyme in the liver which is needed to make cholesterol thereby decreasing the level of cholesterol circulating in the blood. |
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| Suggested Data Collection Question: | Is there documentation that cholesterol reducing medication was prescribed at discharge? |
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| Format: | | Length: | |
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| Type: | Alphanumeric |
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| Occurs: | |
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| Allowable Values: |
Y (Yes, cholesterol reducing therapy was prescribed at discharge)
N (No,cholesterol reducing therapy was not prescribed at discharge OR unable to determine from medical record documentation)
NC (No, cholesterol reducing therapy was not prescribed at discharge. A documented reason exists for not administering this therapy)
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| Notes for Abstraction: |
- If the patient refused prescription for cholesterol reducing therapy at discharge, select “NC”.
- In determining whether cholesterol reducing therapy was prescribed at discharge, it is not uncommon to see conflicting documentation among different medical record sources. For example, the discharge summary may list a drug 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 cholesterol reducing drug noted in one source that is not mentioned in other sources, it should be interpreted as a discharge medication (select “Yes”) unless documentation elsewhere in the medical records suggest that it was NOT prescribed at discharge – Consider it a discharge medication in the absence of contradictory documentation.
- If documentation is contradictory (e.g., MD noted discontinuation of the cholesterol reducing therapy in the discharge medication orders, but it is listed in the discharge summary’s discharge medication list), or after careful examination of circumstances, context, timing, etc., documentation raises enough questions, the case should be deemed “unable to determine” (select “No”).
- When there is a documented plan to delay initiation/restarting of a cholesterol reducing therapy for a time period after discharge, select “No”.
- If documentation by a physician, nurse practitioner, or physician assistant is present in the chart that indicates that the stroke was not of an atherosclerotic origin or that the patient does not meet NCEP ATP III criteria for lipid lowering therapy, select “NC”.
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| Suggested Data Sources: |
- Physician orders
- Discharge summary
- Transfer sheet
- Discharge instruction sheet
- Nursing discharge sheet
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
- Refer to Appendices, Table 3 for a comprehensive list of cholesterol reducing drugs.
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Cholesterol Reducing Therapy Prescribed at Discharge
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
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