Release Notes:
Data Element
Version 2010B
| Data Element Name: | Aspirin Prescribed at Discharge |
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| Collected For: | AMI-2, |
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| Definition: | Documentation that aspirin was prescribed at discharge. Aspirin reduces the tendency of blood to clot by blocking the action of a type of blood cell involved in clotting. Aspirin improves chances of surviving a heart attack and reduces the risk of recurrence in patients who have experienced a heart attack. |
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| Suggested Data Collection Question: | Was aspirin prescribed at discharge? |
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| Format: | | Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
Y (Yes) Aspirin prescribed at discharge.
N (No) Aspirin not prescribed at discharge or unable to determine from medical record documentation.
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| Notes for Abstraction: | In determining whether aspirin was prescribed at discharge, it is not uncommon to see conflicting documentation amongst different medical record sources. For example, the discharge summary may list an aspirin medication 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 aspirin 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 record suggests that it was NOT prescribed at discharge - Consider it a discharge medication in the absence of contradictory documentation.
- If documentation is contradictory (e.g., physician/advanced practice nurse/physician assistant [physician/APN/PA] noted discontinuation of the aspirin 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”).
- If aspirin is listed as a discharge medication, select "Yes" unless contradictory documentation exists (see above). If aspirin is not listed as a discharge medication, and there is only documentation of a plan to delay initiation/restarting of aspirin for a time period after discharge, select “No.”
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| Suggested Data Sources: |
- Physician orders
- Discharge summary
- Transfer sheet
- Discharge instruction sheet
- Medication reconciliation form
- Nursing discharge notes
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
- Refer to Appendix C, Table 1.1 for a comprehensive list of Aspirin and Aspirin-Containing Medications.
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Aspirin Prescribed at Discharge
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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