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Release Notes:
Data Element
Version 2010B

Data Element Name: Reason for Not Administering Antenatal Steroid
Collected For: PC-03,
Definition:Reasons for not administering a full course of antenatal steroids before delivery are clearly documented in the medical record. Reasons for not administering a full course of antenatal steroids may include fetal distress, imminent delivery or other reasons documented by physician/APN/PA/CNM.

A full course of antenatal steroids consists of two doses of 12mg bethamethasone IM 24 hours apart OR four doses of 6 mg dexamethasone IM every 12 hours.

Suggested Data Collection Question:Was there documentation of reasons for not administering a full course of antenatal steroids before delivery?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes) There is documentation by physician/APN/PA/CNM that the patient has one or more reasons for not administering a full course of antenatal steroids before delivery.

N (No) There is no documentation by physician/APN/PA/CNM of a reason for not administering a full course of antenatal steroids before delivery or unable to determine from medical record documentation.

Notes for Abstraction:When determining whether there is a reason documented by a physician/APN/PA or CNM for not administering the full course of antenatal steroids, reasons myst be explicitly documented (e.g., "fetal distress required emergency cesarean section - unable to complete full course of antenatal steroids") or clearly implied (e.g., "delivery is imminent-only one dose of steroid given"). If reasons are not mentioned in the context of antenatal steroid administration, do not make inferences (e.g., Do not assume that the patient did not receive the full course of antenatal steroids because the patient was in active labor upon arrival to the unit.)
Suggested Data Sources:

PHYSICIAN/APN/PA/CNM DOCUMENTATION ONLY

  • History and physical
  • Physician progress notes
  • Prenatal forms
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Reason for Not Administering Antenatal Steroid
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)