Corticosteroids are a family of potent anti-inflammatory medications produced either naturally by the adrenal cortex or manufactured synthetically, in inhaled, topical, oral, and intravenous forms.

• This data element should be answered independently and irrespective of whether the patient was prescribed oral or intravenous (systemic) corticosteroids during this hospitalization.
• When there is documentation of an “allergy”, “sensitivity”, “intolerance”, “adverse or side effects”, regard this as documentation of contraindication regardless of what type of reaction might be noted. Do not attempt to distinguish between true allergies, sensitivities, intolerances, adverse or side effects, etc. (e.g., “Allergies: Systemic Corticosteroids – select “Yes.”)
• The abstractor should search every suggested data source listed for the collection of information. When conflicting information is documented in a medical record, a positive finding should take precedence over a negative finding (e.g., answer “Yes”), unless otherwise specified.
• When determining whether there is a reason documented by a physician/APN/PA or pharmacist for not prescribing oral or intravenous (systemic) corticosteroids during this hospitalization:
  • Reasons must be explicitly documented or clearly implied (e.g., “intolerance to systemic corticosteroids” or “problems with systemic corticosteroids in past.”)

• Consultation notes
• Emergency department record
• History and physical
• Nursing notes
• Progress notes
• Physician orders
• Discharge summary
• Medication administration record (MAR)
• Ambulance record
• Medication reconciliation form
• Records from physician's office, clinic, or transferring facility (must be a part of this current medical record)