• For this data element, documentation by an infection control practitioner is acceptable (in addition to physician/APN/PA or pharmacist documentation) if it is specifically designated as “infection control” documentation. An infection control practitioner may be a medical technician, nurse, physician/APN/PA, or pharmacist.
  Examples:
  • In the progress notes, it is documented, “Patient has a history of MRSA” and it is signed by Nancy Nurse, RN, CIC.
  • In the progress notes, under the heading “Infection Control,” a physician/APN/PA or pharmacist documents that vancomycin is used because of the hospital’s high MRSA rate.
• Physician/APN/PA, pharmacist or infection control practitioner documentation of the reason for the use of Vancomycin as prophylaxis must have been entered into the medical record preoperatively to select Allowable Values 2, 5, 6, 8, and 10. If the documentation was not entered preoperatively, select Value 9- No documented reason/Unable to Determine.
• In order to select allowable value #1 “Documentation of beta-lactam (penicillin or cephalosporin) allergy,” the answer to the data element Antibiotic Allergy must be “Yes.”
• If the medical record contains preprinted orders (signed by a physician) prescribing vancomycin for all valve surgeries, select allowable value #10.

WHERE SPECIFIED IN ALLOWABLE VALUES ABOVE, PHYSICIAN/APN/PA OR PHARMACIST DOCUMENTATION ONLY IS ALLOWED.

• Anesthesia record
• Emergency department record
• History and Physical
• ICU flowsheet
• IV flowsheet
• Medication administration record
• Nurses notes
• Operating room record
• PACU/recovery room record
• Physician’s orders
• Progress notes