Release Notes:
Data Element
Version 2010B
| Data Element Name: | Lipid-Lowering Agent Prescribed at Discharge |
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| Collected For: | AMI-T2, , (CMS Optional Test Measure) |
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| Definition: | Documentation that a lipid-lowering medication was prescribed at hospital discharge. |
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| Suggested Data Collection Question: | Was a lipid-lowering medication 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) Lipid-lowering medication prescribed at discharge
N (No) Lipid-lowering medication not prescribed at discharge or unable to determine from medical record documentation
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| Notes for Abstraction: | In determining whether a lipid-lowering medication was prescribed at discharge, it is not uncommon to see conflicting documentation amongst different medical record sources. For example, the discharge summary may list a lipid-lowering 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 a lipid-lowering medication 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 lipid-lowering medication 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 a lipid-lowering medication is listed as a discharge medication, select "Yes" unless contradictory documentation exists (see above). If a lipid-lowering medication is not listed as a discharge medication, and there is only documentation of a plan to delay initiation/restarting of a lipid-lowering medication 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 1.6 for a comprehensive list of Lipid-Lowering Medications.
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Lipid-Lowering Agent 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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