Release Notes:
Data Element
Version 2010B
| Data Element Name: | Pre-Arrival Lipid-Lowering Agent |
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| Collected For: | AMI-T1a, , (CMS Optional Test Measure) |
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| Definition: | Documentation in the medical record that the patient was on a lipid-lowering medication prior to hospital arrival. |
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| Suggested Data Collection Question: | Is there documentation that the patient was on a lipid-lowering medication prior to hospital arrival? |
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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 a lipid-lowering medication prior to hospital arrival.
N (No) There is no documentation that the patient was on a lipid-lowering medication prior to hospital arrival or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- Refer to the patient’s medication regimen just prior to acute care treatment. Include lipid-lowering medication if the patient was on it at home, the nursing home, a transferring psychiatric hospital, etc.
- Include cases where there is documentation that the patient was prescribed a lipid-lowering medication at home but there is indication it was on temporary hold or the patient has been non-compliant/self-discontinued their medication (e.g., refusal, side effects, cost).
- 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.
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| Suggested Data Sources: |
- Consultation notes
- Emergency department record
- History and physical
- Nursing admission assessment
- Progress notes
- Transfer sheet
- Medication reconciliation form
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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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Pre-Arrival Lipid-Lowering Agent
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)
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