Release Notes:
Data Element
Version 2010B
| Data Element Name: | Beta-Blocker Current Medication |
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| Collected For: | SCIP-Card-2, |
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| Definition: | Documentation in the medical record that the patient was on beta-blocker therapy prior to admission. Beta-blockers are agents which block beta-adrenergic receptors, thereby decreasing the rate and force of heart contractions, and reducing blood pressure. |
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| Suggested Data Collection Question: | Is there documentation that the patient was on beta-blocker therapy prior to admission? |
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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) There is documentation that the patient was on beta-blocker therapy prior to admission.
N (No) There is no documentation that the patient was on beta-blocker therapy prior to admission or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- If there is documentation that the beta-blocker was a “home” or “current” medication, select “Yes.”
- If there is documentation that the beta-blocker was given on a “prn” basis for cardiac or non-cardiac reasons, select “No.”
- If there is documentation that the patient is not taking the beta-blocker, select “No.”
Examples:
- On the patient’s list of medications from home, Atenolol is listed, but the nurse notes that the patient is not taking the medication. Select “No.”
- There is documentation that indicates that the patient stopped taking their beta-blocker prior to surgery, select “No.”
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| Suggested Data Sources: |
- Anesthesia record
- Consultation notes
- History and physical
- Nursing admission assessment
- Progress notes
- Admitting record
- Medication reconciliation form
- Preoperative record
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion |
- Refer to Appendix C, Table 1.3 for a comprehensive list of Beta-Blocker medications.
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- Eye drops containing beta-blocker (e.g., Cosopt)
- “PRN” beta-blocker
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Beta-Blocker Current Medication
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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