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Abstracting for Accuracy
Presented by [Robyn Carlson, RHIA, CPHQ, Stratis Health] (120-minute Webinar) [03-13-2013]
Mary Montury:
Hi everyone and welcome to the Abstracting for Accuracy conference call January 1,
2013 – December 31, 2013, Discharge Changes. Robyn Carlson is our speaker
today and I’m happy to introduce you to her. Many of you know her personally.
Robyn has a broad background in medical record abstraction, review and training.
She has supervised medical records staff in acute care settings as well as provided
client support, consulting for Medi Qual Systems Inc.
In her current role of Quality Report Specialist at Stratis Health, Robyn works with
facilities submitting data to CMS for the hospital inpatient/outpatient quality reporting
program and coordinates the validation process for data submitted to the QIO clinical
warehouse.
Robyn Carlson:
Thank you Mary.
As Mary said, I’m talking about changes for the specification manual version 4.2b for
discharges 1/1/13-12/31/13. This is the year where there’s just going to be one
manual there won’t be a second, but from what we know, next year they will be back
to the two manuals a year. This was a one-time thing for this manual.
Much of what I’ll tell you, for those who have listened for a while, for each new
version of the specifications manual any addendums, like this is 4.2b so you know
there was a 4.2 and 4.2a, you need to review the release notes for a detailed
description of the changes that were made. I’ll be going over the major abstraction
changes, but time-wise I can’t go everything so again it will be your responsibility to
review the release notes for all the changes.
It’s especially important now, in starting with this manual there’s no highlighting to
indicate the changes. We always knew before that things in yellow meant that’s what
was different than the last manual, but there is no more highlighting so the only way
you’ll know what’s different is if you look at the release notes and match one manual
to the next.
We’re going to do things a little different this time. When Mary sent out the email with
the phone number I did mention the elements I will be talking about and we didn’t do
page numbers this time because after we’ve done that we’ve heard from people who
were looking online the page numbers didn’t match to what was given in the email
and people were confused, so we didn’t do the page numbers and these are the data
elements I’ll be talking about.
First, we’ll talk about the changes to the data elements to the clinical topics that
we’ve had for a while… heart failure, pneumonia, SKIP and if there’s any changes to
the immunization and ED and then I’ll stop for questions. From there I’ll discuss the
new data elements for the stroke and the VTE. I wanted to do it this way because I
think there could be quite a few of the critical access hospitals who aren’t choosing to
do the stroke or VTE at this time.
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I didn’t want to keep people on the call if we were talking about topics they weren’t
going to deal with. So we’ll try that this time and see how it works.
There are fact sheets for the topics and I believe we provided a link in the latest
newsletter, but in case someone didn’t get those, if you go on the Quality Net home
page under hospitals inpatient, on the left hand side while you’re looking at the
screen go to the specs manual and on the side you’ll see the fact sheets. They did
add a stroke and VTE fact sheet within the last month, but there isn’t a lot on them
yet.
The first data element I wanted to mention is:
Anesthesia – the change they added there was an inclusion for general anesthesia.
If you see total intravenous anesthesia, apparently it could be abbreviated TIVA,
which is now an inclusion guideline for general anesthesia.
Antibiotic administration – for this… date, time, route and antibiotic name… the
thing that has changed with all of those, you do not abstract test doses of antibiotics.
For the antibiotic guidelines under the SKIP it says do not abstract test doses of
antibiotics and that’s different from before because we were picking those up, so
that’s a change.
Beta Blocker Current Medication– there are no actual changes on how to abstract
this measure. There was just clarification, because in the last manual they made a lot
of changes and people had difficulty figuring out how they were supposed to abstract.
It looks like there are quite a few notes for abstraction now, but it’s just clarifications.
You shouldn’t really change the way you were abstracting, this is helping those who
were maybe unsure of how to do it.
There are instructions about beta blocker prior to surgery, so they provided better
clarifications on when you should say yes or no, such as instructions about
determining whether a beta blocker is a home or current med. They talked about the
dosing frequency and then guidelines regarding conflicting documentation were
added.
I don’t want to go over all these, you can read them yourselves but I believe the
purpose of the measure is they want to know was the patient on a daily beta blocker
prior to arrival. I think this helps clarify when you want to say yes or no.
Beta Blocker Peri Operative – this is sort of the same thing. There are no changes
to how we abstract, but again they gave you more clarification because people had
questions about selecting all the values that apply.
So if you select value one, was a beta blocker received on the day prior to surgery.
To select value one there must be a date or other documentation that the last dose of
the beta blocker was taken on the day prior to the day of surgery. This can include a
date for the last dose or specified documentation on the day of surgery that the
patient took the beta blocker on the day before surgery, such as patient states they
took the beta blocker last night before bed or states took the beta blocker yesterday.
That would be acceptable for indicating that the beta blocker was taken on the day
prior to surgery.
Comfort Measures – there were changes to provide clarification, to improve the
consistency and to reduce the false measure exclusion. They tried to fix it so we
weren’t picking up comfort measures only in indications where those words are being
used, but we all knew well from looking at the chart it wasn’t a comfort measures
only. Hopefully, some of the clarifications they’ve made will help us determine that
easier.
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They changed the definition and tried to explain again what they mean by comfort
measures only and you can read that.
Giving some of the bullets that were changed, the six bullets where it talks about
preprinted order forms, give a little more explanation. Disregard an inclusion term in a
statement that is not part of the order or that is not clearly selected. What they’re
talking about is maybe an order form that gives you a variety of options and just
because the title of the form says comfort measures or comfort, if it’s clear from the
from that they aren’t checking that off or it’s not what is being used then don’t
automatically say comfort care, just because it’s the title of a form.
On the last bullet, if there’s a specific option on a form that says comfort measures
only and it’s not checked, then you won’t say this is comfort measures only. It would
have to be checked on the form regardless of what kind of form it is. Even if it’s the
physician’s orders for life sustaining treatment form, something like that still needs
indication that the comfort measures only still applies.
Next they provide more examples of when things are negative. It does say
documentation of comfort measures only should be disregarded if documentation
makes clear it is not being used as an acronym for comfort measures only. So
apparently we found that CMO was meaning other things and the example they gave
there was history of dilated CMO and in that instance they’re talking about
cardiomyopathy context. If it’s not comfort measures only then don’t pick it up as yes.
The only thing else I want to add to that is for the acceptable sources they added the
emergency department record. That is now listed as an acceptable source. It’s still to
say only in the following only acceptable sources, so H & P are still not included
there.
Data Element Compromised – They changed the definition a bit. It notes since the
patient has a clinical condition that could justify alternative antibiotic treatment. They
added that to… or is on therapy which puts them at a higher risk for infection.
They also added to the last bullet on pg. 116. If there is position, APNPA
documentation within 24 hours after hospital arrival that the patient has prolonged QT
interval then you can select value one, so they added that as being a compromising
condition.
Discharge Disposition – There are some new bullets. The new bullet added is
something we’ve always talked about, but I think this is the first time they’ve actually
put it in the manual. The bullet states: “the medical record must be abstracted as
documented. Inferences should not be made based on internal knowledge.” I think
that’s the issue we sometimes have a lot with discharge positions, because you know
where the patient is going and the name of this place is this or that kind of facility.
With the stated element there’s no knowing anything. It’s all about what’s
documented, so they’ve added bullets to reinforce that.
On page 127, the fourth bullet down says: “if documentation is contradictory and you
are unable to determine the latest documentation, select the disposition ranked
highest top to bottom in the following list.” This is a new bullet. You should select the
acute care facility if you had more than one option, but if one was an acute care
facility that’s what you would pick. Next, it would be hospice for health care facility.
Next would be hospice home and then it would be other health care facility, followed
by home.
If you have more than one, that’s the order that you pick where the patient is being
discharged to from top to bottom.
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The next bullet hospice… so values 2 & 3, which is hospice home or hospice
healthcare facility, that includes discharges with hospice, referrals and evaluations.
Bullet 7 is what I referred to earlier, if the medical record identifies the facility the
patient is being discharged to by name only and does not reflect the type of facility or
the level of care, select value 5 as other healthcare facility. Remember it doesn’t
matter what you know if I came in to look at your records and didn’t know anything
about the names of these places, we should still be abstracting the same.
Next bullet… if the medical record states only if the patient is being discharged and
doesn’t address the place or setting to which the patient was discharged then select
value one home. Again, this might not be a change for any of you this is how we
should have been abstracting but this is the first time this has actually been down as
notes for abstraction.
I think they further clarified when determining whether to select value 7 left against
medical advice, which you can look at.
On page 128 they provided additional guidelines of what fits under each one of the
values. What’s under home, under hospice and what’s considered to be acute care
facility, other healthcare facility? Those are just some guidelines to help you better
pick which value you wanted to take.
ECG Interpretation– initially they added a step to the methodology on the bottom of
page 239. Number one says identify the ECG performed closest to arrival either
before or after hospital arrival but not more than one hour prior to arrival. That was
always there, but if you’re unable to determine which ECG was performed closest to
arrival select no, that was there. Now the exception, if the pre-arrival ECG and the
first ECG performed after arrival at the hospital are the same amount of time away
from hospital use the first ECG performed after hospital arrival.
The example they give if you have both ECGs and they are 10 minutes away from
arrival time, one is 10 minutes before one is 10 minutes after, then you’ll want to use
the one performed after hospital arrival.
On page 241 for inclusions, they added stemi or equivalent. If you see that you could
consider that to be an inclusion word.
On page 242 where they’re talking about exclusion terms, down the fourth bullet, ST
elevation with any mention of early re-polarization, that’s just a clarification. Further
down ST segment elevation or any of the other ST segment elevation inclusion terms
with any mention of pacemaker pacing in one interpretation.
The last bullet says all ST elevations in one interpretation is described in one or more
of the following ways. They added non-specific, so if you see non-specific ST
elevation that’s considered an exclusion term. How you abstract the ECG hasn’t
changed, you still look for exclusions first. If you find an exclusion you stop and if you
don’t than you can look for an inclusion and if you have an inclusion then you can
record yes.
Observation Services– pg 276– there’s a change to this one, so please note.
Starting with January 1, 2013 discharges the question is now… was there
documentation of an order for observation services written by the physician, APN PA.
So we’re looking for an order. The only allowable source is a physician order. The
notes for abstraction, if there’s documentation of an order for observation services
and the patient receives care and observation, select yes.
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They’re just asking to see an order for observation services that no longer matters if
the observation was in the ER or outside the ER, it doesn’t matter where it’s just like
you’re looking for an order for observation services. If there was an order then you’ll
select yes. If t here was not an order ten you would select no. That’s different than
previously, but don’t start this now until you’re doing fourth quarter. For fourth quarter
data still use the old way, you had to see whether it was observation in the ED or
observation outside the ED, so this starts with January 1, 2013 discharges.
Nested Element– this is the pneumococcal vaccination status, pg 298 if you’re in the
manual. They removed the references here to the PTV 23 because they’re no longer
just looking at that vaccination, so it’s the pneumococcal vaccine, whichever type
they get.
Then the allowable values, the last bullet under number four, they changed the age
range. Now the guidelines say patients 5-18 years of age. I think before it said older
than 6. Then on page 299, the fifth bullet down again is the age range and children 518 years of age. It’s defining the age range for us.
On page 319, reasons for delay in fibrinolytic therapy… there isn’t any change to how
you collect this. What they did was change the wording. Previously it talked about
balloon pump and now instead of just being balloon pump its mechanical circulatory
assist device placement, which is the phrase they’ve inserted instead of balloon
pump. Mostly you’ll notice that on page 320, on the first page the exceptions…
physician APN or PA documentation that a cardiopulmonary arrest, mechanical
circulatory assist device placement and again before it said balloon pump insertion.
Down under the inclusion guidelines, mechanical circulatory assist devices, that’s
where you see balloon pump and they’ve added some of the other devices that
would fit under that, broadening the category.
On page 322, the reason for delay in PCI. Nothing changed on how we collect it, they
just changed the terminology so it’s no longer just the balloon pump it’s the
mechanical circulatory assist device placement.
On page 359, reasons for not administering beta blocker peri operative… no change
really in how to abstract. Again, more clarifications because this was another where
back in the last manual they made a lot of changes where we now have the five
allowable values and you need to indicate if it’s a reason for not administering it on
the day prior to or the day of surgery. People were getting confused so they added
bullets to help clarify how to pick that up. There are a lot of bullets.
On page 360… the main one bullet three… if the beta blocker was held on the day
prior to hospital arrival and prior to the day of surgery, the reason it was held or not
taken can be documented on the day of surgery. There must be a reason
documented for each day the beta blocker is held or not administered to select the
corresponding value.
Pre-operative documentation that the patient is NPO or due to NPO status alone is
not acceptable to select values 1-4, so that in and of itself won’t be acceptable for a
reason.
The last bullet was added, on page 360, patient refusal does not have to be
documented by a physician APN or PA but must be documented in the timeframe
corresponding to the timeframe for the value being abstracted.
You can read that. Nursing documentation is okay, but it still has to be within the
timeframe for the value.
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The next stated element is reasons for continuing
page 387 in the manual. They’ve added to this,
reasons may include still ICU placement but
vasopressors, anatropic or paralytic therapy, so
diuretic.
urinary catheterization – that is
instead of only being a diuretic,
now it’s with a diuretic or a
it’s more than just being on a
You’ll note also that value 1 has changed. There’s documentation that the patient
was in the intensive care unit, that’s the same, but now it’s and receiving one or
more of the listed medications.
The notes for abstraction–
Value 1 does not require physician APN or PA documentation. If the patient is in the
intensive care unit on post update one or two and it’s documented that the patient
receives even one dose of diuretics, vasopressors, anatropics or paralytics, you can
select value one. So for any notes on abstraction, everything that’s been added is
where before it just said diuretics and now these other medications are added as
well.
On page 389 there is Appendix C which is where you’ll have a lot of the tables for the
different medications. On this page it’s telling you that in Appendix C of the
specifications manual table 3.13 is the list for the diuretics. Now we’ve added table
3.14 for the list of anatropic and vasopressor agents and 3.15 for a list of paralytic
agents. So you don’t have to be totally familiar with the meds, but we’re giving you
the list for what you need to look at.
The last thing to touch on for the topics is the qualifiers and modifiers table– this is
in the appendices of the manual, so if you’re looking online it’s the last line of the
manual. This is Appendix H and it’s table 2.6 called qualifiers and modifiers table and
they’ve added to this so I wanted to point out they added… might under qualifiers. So
things on this list are negative, if you see might be or might have or might have been,
might have had or might indicate those would be considered negative.
Under the modifiers they added no significance and minor, which is a negative finding
but these guidelines only apply to both data elements that refer to them in their
guidelines. So, in the manual when you’re looking under that data element and one
of the notes for abstraction says if this word has any of the qualifiers or modifiers it
would be excluded that’s when you look here, you don’t just look here for all the data
elements and that’s the note on the bottom. These guidelines apply only to those
data elements that refer to them in their guidelines for abstraction exclusion lists.
Not everything applies to this.
I went through those faster than I expected, but there aren’t that many changes to the
normal clinical topics, so what I want to do now is see if there are any questions
about these before I move forward to talk about the VTE and stroke data elements.
Let’s move forward and talk about the stroke data elements. I’ll mention again the
population. I know some of you may have been collecting the stroke data and VTE
data elements. They’ve been in the manual and available but since they are new for
CMS as of January 1, 2013, I want to make mention of them. If there’s something I’ve
heard something about or think that you should pay attention to, I will mention that.
I want to talk first about the population for stroke and this is from the manual, but your
population for your stroke patients… patients admitted to the hospital for inpatient
acute care with an ICD9 CM principle diagnosis code for ischemic or hemorrhagic
stroke as defined in Appendix A table 8.1 or 8.2.
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Any time we’re talking about tables it’s going to be in the appendices of the manual,
which is the first thing you need to do is look to see if they have a code on 8.1 or 8.2.
You need to have a patient age greater than or equal to 18 years and a length of stay
less than or equal to 120 days. That’s how you determine your stroke population.
After that it’s the same as your other clinical topics. There will be guidelines if you
want to sample or not and that information is also in the manual just like all the
others. If this is new to you then that’s how you determine what your stroke
population should be.
I’m going to point out the data elements that are part of the stroke measures. There
are some data elements that you collect for everything and you’re already collecting
those so we aren’t going to talk about them, but I want to point out to people who, if
this is your first time for stroke these are the data elements you’ll be collecting for the
stroke measures.
First is on page 67, the anticoagulation therapy prescribed at discharge. Was the
anticoagulation therapy prescribed at discharge? It’s yes or no. This discharge data
element like this was therapy prescribed. It’s sort of like how when you’re abstracting
the heart failure, the other medications we’ve done for all the other topics. Was it
prescribed at discharge? The notes for abstraction are the same. As we do for was
there aspirin at discharge or a beta blocker? It’s that same kind of instruction.
I want to point out on page 68 for the inclusion, we have a table in Appendix C it’s
table 8.3 which is your list of medications used for anticoagulation therapy. They
don’t say they’re all inclusive but I think you have the ones that are used most often,
unless there’s some new medication but for now just familiarize yourself with these
medications.
On page 68 the next element is antithrombotic administered by end of hospital
day two– Was antithrombotic therapy administered by the end of hospital day two? If
it was yes. If it wasn’t or you can’t determine than it’s no. The notes for abstraction
here it’s just in case there’s some question about how to figure out the end of hospital
day two, to compute that count the arrival date as hospital day one. If the
antithrombotic therapy was administered by 11:59 p.m. of hospital day two than you
would select yes.
Documentation of antithrombotic administration must be found within the timeframe
of arrival to the end of hospital day two. It is not necessary to review documentation
outside this timeframe to answer this data element. So they need that information to
be in that timeframe. If it’s outside of that even if it was given you won’t pick it up
because it doesn’t meet the timeframe.
On page 70 it tells you under the inclusions, you have the list. This is our table 8.2 for
the list of medications used for antithrombotic therapy.
On page 71 the data element antithrombotic therapy prescribed at discharge–
was the antithrombotic prescribed at discharge. Again the instructions are the same
as the way we look for all our meds prescribed at discharge.
On page 85, the data elements assessed for rehabilitation services– was the
patient assessed for and/or did the patient receive rehabilitation services during this
hospitalization? Values are yes they did or not they didn’t. Notes for abstraction… the
assessment for rehab services must be completed by a qualified provider. You have
an inclusion list on the next page for acceptable examples of documentation and it
says the list is not all inclusive.
If a documented reason exists for not completing a rehab assessment select yes.
They provide examples of what would be considered a documented reason.
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



Patient returned to prior level of function
Rehab not indicated at this time
Patient unable to tolerate rehab therapeutic regimen
Patient family refusal
So if you have one of those you could say yes for this one. Do not infer that
documentation of symptoms resolved means that a rehab assessment was complete,
unless mentioned in the context of rehab services. For example, symptoms resolved
no rehab needed.
I think a lot of these findings for the stroke measures and the VTE are very clear that
you need to specifically see documentation. They don’t want us making any
judgments about patient has this or that condition which means this isn’t needed.
They really want to see documentation about the why.
The last bullet on page 85, when an assessment is not found in the medical records
but documentation indicates that rehab services were initiated. For example, PT, OT,
speech/language therapy for neurophysiology, if those were done during the stay
then you can select yes.
On page 86, the last bullet when patient is transferred to a rehab facility or referred to
rehab services following discharge than again we could say yes for this data element.
The exclusion may be a good thing to note there. Exclude a nursing assessment for
activities of daily living. They are looking for more than that. Under inclusion
guidelines, assessment or consult done by members of the rehab team, if you have a
team and it’s listing who would be included in that... physician, physical therapist, etc.
Another new data element for the stroke measures is atrial fibrillation or flutter. So
what there a history of atrial fibrillation or flutter or a current finding of atrial fibrillation
or flutter documented in the medical record? Yes or no. It does say in the notes for
abstraction if there was a history of or current finding then you could say yes. If the
documentation of atrial fib or flutter is on a current EKG you could say yes also.
Documents anywhere in the medical record its yes. If there was a history of an
oblation procedure you could say yes. If there’s a history of transient and entirely
reversible episode of atrial fibrillation or flutter due to thyroid toxicosis than it would
be no.
Inclusion guidelines, if you do have a discharge with an ICD9 CM other diagnosis
code of 42731 or 42732 for the atrial fib or flutter that would be acceptable. I don’t
think this will be a difficult data element, just familiarize yourself with what you’re
looking for and what can be included.
Next, the new finding for stroke is date last known well. They want to know the date
at which the patient was last known to be well or at his/her baseline state of health. At
the bottom of page 118, the last bullet, if you don’t have an actual date documented
but there’s reference to the date described in the medical record, like if it said today,
tonight or this evening, assume that the date last known well is the same as the date
for that timeframe proceeding hospital arrival.
For example, wife reports patient normal this evening. Hospital arrival is at 0030 on
12/10/20, date of last known well would be 12/9/20 and that should make sense to
everyone. If they arrived after midnight and the wife is saying the patient was normal
this evening, then you could do the day prior to that actual arrival. That bullet does
say the date last known well and the arrival date may be the same date or a different
date. That’s acceptable and that example shows where that might happen.
On page 119, the first bullet, if there are multiple dates of last known well use the
date recorded according to the hierarchy.
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You would want to look at neurology documentation first. So if you had a neurologist
saying something then that would be the day you would take first. Admitting physician
second, emergency department physician third, ED nursing notes fourth and
information from EMS would be fifth. So, if you have more than one that’s your
hierarchy to use. If you have multiple dates documented by the same provider use
the earliest date recorded for the date last known well.
We have a lot of findings in the stroke measures regarding education. I think a main
thing to note is for these education data elements the part that’s the same as when
we’re doing the heart failure and you’ve got the discharge instructions, address, diet
and activity. For these education data elements it’s the same thing in that it must be
written instructions given to the patient or their caregiver. It can’t just be that they’re
taught or you just can’t know that everybody gets this, there needs to be
documentation that written instructions were given.
The first one on page 161, education addresses activation of emergency medical
system. We want to know if the written instructions or other documentation of
educational material given to the patient or caregiver, address activation of the
emergency medical system (EMS) if symptoms of stroke occurred. They’re looking
for education material or instructions that say for something like, call 9-1-1
immediately if there’s sudden numbness or weakness of an extremity is noted. It
needs to tell the patient contact 9-1-1 if you have these symptoms.
On page 162 third bullet down, which will be on all instructions for the stroke, if
documentation indicates that the written instructions or materials were not give
because the patient is cognitively impaired (comatose, confused, have short-term
memory loss) and there’s no caregiver with them, then you can select yes. You don’t
want to say on the measure because you would give instruction to the patient if they
could understand it but if they can’t then…
All of these for the stroke will have this bullet, so remember if the patient is cognitively
impaired and has no caregiver with them than you can say yes but if there’s a
caregiver there and then the last bullet defines the caregiver. Patient’s family or any
other person like Home Health, if they’re going to with other law enforcement
personnel, if there’s someone taking that patient somewhere and will be responsible
for the care of the patient after discharge then that’s the caregiver. Then we need
written instructions noted as given to that person.
For EMS we’re looking for something that says either EMS or 9-1-1 and telling them
about the signs and symptoms of stroke. Some are listed here, numbness,
weakness, sudden confusion and trouble seeing that’s values under warning signs
and symptoms.
On page 163 the education addressed follow up after discharge. It’s the same kind of
saying, written instructions given.
On page 165, education addresses medications prescribed at discharge. You’re all
familiar with that. It’s the same thing you would do in regards to heart failure.
On page 169, education addresses risk factors for stroke. The first notes for
abstraction, educational material must specifically address risk factors for stroke and
it provides examples.
On page 170 there’s an inclusion list of risk factors for stroke, but the third bullet
down, individual risk factors that are not mentioned in the context of education
provided on the risk factors for stroke do not count. For example, discharge
instruction to limit alcohol. Without explicit documentation that excessive alcohol
consumption is a risk factor for stroke then you wouldn’t want to say yes to that.
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On page 172, education addresses warning signs and symptoms of stroke. The
bullets there include instructions with address what to do. For example, call 9-1-1
immediately, sudden numbness or weakness of an extremity is noted. So written
instructions on what to do if there are warning signs. On page 173 they provide some
of the acceptable warning signs.
The biggest thing to note on these pretty much just like your heart failure instructions,
written instructions or any kind of educational material must be written and then if the
patient themselves are cognitively impaired with no caregiver than again you can say
yes.
On page 174, new data element for stroke is, was this admission for the sole purpose
of performance of an elective carotid intervention? The values are yes or no. The
notes for abstraction it’s around elective. So patients admitted for an acute stroke are
not considered to have been admitted solely for the purpose of the performance of
elective carotid intervention. You’re looking for the fact that this was elective.
If the patient was admitted for an acute stroke, even if a carotid intervention was
performed after admission you select no, because they weren’t admitted for an
elective carotid intervention. This is like right off the bat you know this person is
coming in because they’re having this done it’s elective.
On page 175, for the inclusion guidelines it’s giving you a table for a procedure code
that constitutes a carotid intervention procedure. So, if the patient has a procedure
code on table 8.3 and the documentation indicates one of the phrases for elective
there, planned, previously scheduled, anything that’s listed as elective then you
would say yes to this one.
On page 246, IV or IA thrombolytic therapy administered at hospital or within 24
hrs prior to arrival– did the patient receive intravenous or inter arterial thrombolytic
therapy at this hospital or within 24 hrs prior to arrival? It’s just going to be yes if they
did and no if they didn’t. It lists the only acceptable thrombolytic therapy for stroke
and it’s giving you the medications you can look for.
IV thrombolytic initiation– is there documentation that IV thrombolytic therapy was
initiated at the hospital? Yes if it was, no if it wasn’t or if you can’t determine. Notes
for abstraction say that hang time or infusion time if that’s documented is acceptable.
If it was done prior to arrival at your hospital you’ll say no. If the patient was
transferred to the hospital and the IV was infusing than it will be no, because you’re
looking to see if it was initiated at this hospital.
With the fourth bullet there is a time guideline. When IV thrombolytic therapy is
initiated beyond three hours or 180 minutes then you’ll select no and it provides
examples.
On page 250/252, if you are answering yes to the IV thrombolytic initiation then you’ll
put the date of the initiation and time.
On page 254 is last known well. I think before we talked about the date, now it’s is
there documentation of the date and time of last known well was witnessed or
reported? You’re looking to see if there is documentation of the date and time of last
known well was witnessed or reported, yes or no. Note for abstraction, I this one I
think can be tricky. In order to abstract yes, both the date and time of the last known
well must be documented. You have to have both.
The fourth bullet down says if there’s documentation referencing that the patient was
discovered with symptoms already present and a date or time of last known well
cannot be determined then you select no.
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For example, patient okay last night. Went to bed and woke up in the a.m. unable to
move right arm and leg. They were okay last night but you don’t have a date and time
last known well, it was just sometime during the night so you have to say no.
On page 255 the last bullet for notes on abstraction, the patient may self report the
date and time or the date and time may be reported by a family member, caregiver or
someone else, but the thing to remember is you need a date and time to say yes.
On page 257, they’re asking to look for an LDL greater than or equal to 100 in the
first 48 hours or within 30 days prior to hospital arrival. We’ve looked for the LDL
before for some of the AMI measures. This is for the stroke.
On page 261, was the LDL cholesterol measured within the first 48 hours or 30 days
prior to hospital arrival? So you’re looking for an LDL. It gives some inclusion
guidelines if the wording is different.
On page 308, a pre-arrival lipid lowering agent. Was there documentation that the
patient was on a lipid lowering medication prior to hospital arrival? It’s yes or no and
the same notes for abstraction… when conflicting information is documented in this
instance you say yes. I think this is another thing with some of these stroke and VTE
findings in the past some findings have been conflicting and you might say no in
some of these instances and some you’ll say yes. So if you’re going to start
abstracting stroke now and you haven’t done a stroke or VTE before, you really need
to familiarize yourself with these notes for abstraction before you start.
Some of these measures have different guidelines, especially when you get to the
VTE measures. They are different than what you do for SKIP and what you do for
SKIP hasn’t changed, but they’re different measures when doing the VTE topic itself.
I think you need to look through the manual and the notes for abstraction for some of
these new ones. At the bottom of 308 is a table for a list of lipid lowering medications.
On page 356 is a reason for not administering antithrombotic therapy by the end of
hospital day two. This gives you a specific it’s not by discharge but by the end of day
two. Is there documentation by a physician, advanced practice nurse or physician’s
assistant or pharmacist in the medical record as a reason for not administering
antithrombotic therapy by the end of hospital day two?
Under notes for abstraction it tells you how to figure out what would be the end of
hospital day two. The second bullet says reason for not administering antithrombotic
therapy must be documented by a physician APN PA or pharmacist with one
exception. Patient family refusal does not have to be documented by those
individuals. That could be nurse documentation, but it must be documented in the
timeframe of arrival to the end of hospital day two. Refusal can be done by anyone.
Third bullet, if reasons are not mentioned in the context of antithrombotics do not
make inferences. Don’t assume that antithrombotic therapy was not administered
because of a bleeding disorder unless documentation explicitly states so. You need
to have reasons from the physician.
On page 357 you have your suggested data sources and inclusion guidelines. Some
of the reasons you might see from not administering are at the bottom, but you still
need to have the physician saying that’s why they aren’t and that was the bullet I just
read. If you’re reading about the bleeding disorder or the patient has an aortic
dissection, if you see that you can’t just infer that’s a reason, the physician needs to
say we aren’t administering antithrombotic therapy because patient has aortic
dissection or extensive metastatic cancer. You can’t just see those inclusions and
make that inference.
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On page 359 is reason for not initiating IV thrombolytic. You’re looking at why they
didn’t provide an IV thrombolytic if they didn’t. Notes for abstraction, reasons for not
initiating an IV thrombolytic therapy must be documented by a physician. APN PA,
pharmacist with three exceptions…
1. Patient family refusal
2. NIHS stroke scale – score of zero that can be a reason
3. If you had initiation of the inter arterial thrombolytic at a transferring hospital
… that may be documented by a nurse. Again big bullet, if reasons aren’t mentioned
in the context of IV thrombolytics do not make inferences.
On page 370 is just your inclusion and exclusions.
On page 371 reasons for not prescribing anticoagulation therapy at discharge. Is
there documentation by a physician, APN PA or pharmacist with a reason for not
prescribing anticoagulation therapy at hospital discharge? Again, if reasons aren’t
mentioned in the context of anticoagulation therapy do not make inferences and
assume it wasn’t done because the patient had a bleeding disorder or whatever. You
have to see it wasn’t given because…the physician needs to state.
On page 372, these are similar exceptions we have for all our meds at discharge.
You are familiar with those.
On page 421 is time last known well. We talked about date last known well and last
known well in general and this is the time. Do you know the time of last known well?
On page 422 I want you to look at a couple bullets because it’s trying to figure out a
time if a specific time wasn’t given. The second bullet on 422 is, if the time last known
well is documented as being a specific number of hours prior to arrival. For example,
if the documentation says felt left side going on two hours ago. You would subtract
that number from the time of ED arrival and enter that time.
The next bullet is time last known well is noted to be a range of time prior to arrival. If
they say left side go number two to three hours ago. Take the max time (3 hrs) and
subtract that time from the time of their arrival and use that. Again, you have your
hierarchy if there are multiple times of last known well, use the time documented by
neurology first then the admitting physician then the emergency department
physician then the ED nursing notes or last is EMS documentation.
Those were data elements pertained, the new elements we didn’t have before that
were for the stroke measures. We have a few data elements that pertain to both
stroke and VTE measures. I am going to briefly go over those next and then we’ll talk
a little about the VTE population, how you figure that out and then talk about the VTE
data elements.
If you’re following along in the manual… page 449… is VTE prophylaxis. What type
of VTE prophylaxis was documented in the medical records? If you do SKIP data, if
you do that measure than this will look familiar to you but there are different rules for
the VTE and the stroke.
You’ll know the way this page is set up you’ve got your allowable values, but you’ll
see on the bottom of page 449 that your notes for abstraction is the SKIP note for
abstraction.
On page 450, middle of the page is the note for VTE, so if you’re doing a VTE chart
and abstract VTE prophylaxis, the VTE note for abstraction says… abstract the initial
VTE prophylaxis that was administered the day of or day after hospital admission or
the day of or day after surgery end date for surgeries that start the day of or day after
hospital admission.
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It’s a different thought process and timeframe if you’re doing this data element for the
VTE measure. If you don’t have any VTE prophylaxis administered during this
timeframe it tells you you’re going to select value A which is none of the above and
then you need to look for a reason for no VTE prophylaxis. So, if you’re doing this for
the stroke measure the next note for abstraction is for stroke. Abstract the initial VTE
prophylaxis that was administered the day of or day after hospital admission. So they
aren’t asking you about any surgeries in this one and if none was administered
during that timeframe you’ll select A and then again look for a reason for no VTE
prophylaxis.
It’s a little bit of a different thought than what you do for SKIP. Then the following
near the end of the page on 450, these are your notes for both VTE and stroke. So
you’re looking for values 1-8 of any prophylaxis that was initially administered on the
same date. You only want to select prophylaxis if there’s documentation that it was
administered.
On page 451, you’ll note that for prophylaxis for SKIP we needed orders but you’ll
notice halfway down for stroke or VTE it’s pharmacological and mechanical and tells
you where you can look for the findings. We have an Appendix H table 2.1 which is a
VTE prophylaxis inclusion table that gives you for your different values the different
prophylaxis that fits under your IPC and GCS, the stuff that fits under that.
On page 452 is the VTE prophylaxis date, so for the stroke and VTE if you’re doing
these measures they want to know what was the date of the initial VTE prophylaxis
administered after hospital admission? If you have more than one, they only want the
date of the initial one that was given.
If you’re looking for what was given then you know you’ll have t he reasons why it
wasn’t give and that’s on page 350. Is there documentation of why VTE prophylaxis
was not administered? If none was given for the last values we talked about, this is
where you will come to see if there is documentation why VTE prophylaxis was not
administered.
You really need to look through the notes for abstraction because it’s a different
thought process. There are different values and when you can record things as there
were for the SKIP VTE. First, under notes for abstraction, if the VTE prophylaxis is
administered the day of or day after hospital admission or the surgery end date, this
data element isn’t required because it was given. However, there is an exception
there that you need to note for stroke patients.
Stroke patients require a documented reason for not administering another form of
prophylaxis when graduated compression stockings are the only form of VTE
administered. So if you have a stroke patient and all they got was graduated
compression stockings, hopefully you have another reason why something else
wasn’t given, otherwise, you won’t be able to answer yes to this.
Documentation is a reason for no VTE prophylaxis must be written by the day after
hospital admission or surgery end date. Reasons for not administering VTE
prophylaxis must be documented by a physician APN, PA, pharmacist and the
exception is patient refusal or a risk assessment which can be completed by a nurse.
If reasons aren’t mentioned in the context of VTE prophylaxis do not make
inferences. You can’t just say the patient has a breathing disorder so they weren’t
given any you have to have a reason why a physician didn’t administer the
prophylaxis.
On page 351, you need to read through these because there’s a situation with
determination of low risk or determination of being at risk. We didn’t have this with the
SKIP VTE.
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People have been abstracting some of this and have asked questions and I want to
point out the second bullet there, for patients determined to be at low risk for VTE. If
there’s documentation of no VTE prophylaxis needed then it can be inferred that both
mechanical and pharmacological options were not indicated for the patient and you
can say yes. So, if you have information that the patient is at low risk that is enough
to indicate that both mechanical and pharmacological weren’t needed. However, the
third bullet listed, if they are determined to be at risk than both pharmacological and
mechanical have to be addressed.
On page 352, the last bullet at the top, patient family refusal may be documented by
a nurse but should be documented within the same timeframe as a reason for no
VTE prophylaxis. Patient or family refusal of any form of prophylaxis is acceptable to
select yes. For example, the patient refused heparin, you can select yes. It doesn’t
mean that there’s no reason then for mechanical if they refuse heparin. If patient
refused then you can answer yes to this question.
On page 383, that’s both a new data element for stroke and VTE. Reason for oral
factor XA inhibitor. Is there physician, APN PA document why oral factor XA inhibitor
was administered for VTE prophylaxis? The notes for abstraction, only acceptable
reasons identified in the list of inclusions no other reasons will be accepted.
Therefore you have to have one of these documented reasons if the physician gave
the oral factor XA inhibitor for VTE prophylaxis. Pretty much based around atrial
fibrillation or flutter and total hip or knee replacement surgery and these inclusions
are on page 384.
Those are your stroke data elements. We’ll go over some of the new data elements
for the VTE now.
The first I want to mention are discharge instructions and these are related to
discharge instructions around the patient getting warfarin. We’re talking about written
discharge instructions, documentation and educational material and again all of these
are related to instructions for warfarin.
On page 132 is discharge instructions addressed compliance issues and what you
need to know is the bullets on this one, documentation addresses compliance issues
must include all the following to select yes. The importance of taking warfarin as
instructed and the importance of monitoring warfarin with scheduled PT INR blood
drive. You have to see both of those in the education material or instructions to select
yes for this.
On page 136 is discharge instructions addressed dietary advice for the VTE
measure. The notes for abstraction on this is documentation that addresses dietary
advice must include all the following in order to select yes. Needs to talk about a
consistent amount of foods with vitamin k and then avoid major changes in dietary
habits or notify health professional before changing habits. Therefore, you have to
have written documentation with those two elements to select yes.
On page 140 discharge instructions address follow monitoring. This one,
documentation addresses follow up monitoring must include the following in order to
select yes. Information about plans to monitor warfarin post discharge. For example,
if it says follow up with coumadin clinic in one week that would be acceptable. If you
have home health that would monitoring warfarin and that also would be yes, but you
have to have information about monitoring for warfarin.
On page 146, the last discharge instructions regarding the warfarin, is discharge
instructions address potential for adverse drug reactions and interactions. The notes
for abstraction says what has to be included. Documentation that addresses potential
for adverse drug reactions and interactions must include all the following in order to
say yes. Information that diet and medication can affect the PT INR level.
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Do not take or discontinue any medication or over the counter medication, except on
the advice of a physician or pharmacist and information that warfarin increases the
risk of bleeding. So you have to have instructions that include those three elements.
We have a couple new findings regarding ICU here.
On page 218 is ICU admission or transfer and this is the data element that you do
for pneumonia, but the addition here… for pneumonia you had a certain timeframe
for your value, but on page 219 you’ll see halfway down the page is the instruction for
VTE and the patient was admitted or transferred to the ICU any time during this
hospitalization, so for the VTE if you’re abstracting the case for the VTE then you’ll
pick this up for admitted or transferred to the ICU any time, not just within the 24
hours like you would for pneumonia.
On page 221 is just ICU regarding the VTE measure. It’s ICU admission or transfer
date. What is the date the order was written for the ICU admission or transfer? You’re
looking for when the order was made. On the sixth bullet down, abstract the date that
the admission or transfer was ordered regardless of whether the patient is physically
admitted to the ICU on the same day. You’re looking for when the order was done.
On page 223, the last ICU data element is what date was the order written for the
patient to be discharged from the ICU? You can figure this out it’s not difficult.
On page 225 this is another new data element for the VTE it’s ICU VTE prophylaxis.
These will be for your patients who were in the ICU, what type of VTE prophylaxis
was initially administered in the ICU? Your values are the same as we’ve done for
prophylaxis before. Your notes for abstraction, abstract the initial ICU VTE
prophylaxis that was administered the day of or the day after ICU admission or the
day of or day after surgery end date for surgeries the day of or day after ICU
admission.
If no ICU VTE prophylaxis was administered during this timeframe you’ll select value
A which is none and then you have to look for a reason for no VTE prophylaxis ICU
admission.
When you’re looking for the VTE data elements you have one for patients who were
seen in the ICU and then your VTE prophylaxis for those who weren’t. How you
collect things is just going to be a matter of the timing and were they in the ICU or
not. Also, I should mention there’s a table in Appendix H table 2.1, that’s your VTE
prophylaxis inclusion table. For any prophylaxis refer to this table to see if what you
were given fits under the inclusions.
On page 243 is the INR value, which is a new finding the for the VTE measures. Was
there documentation of an INR value greater than or equal to two prior to
discontinuation of the parenteral anticoagulation therapy? So to determine the value
for this data element you’ll have to review the INR values the day of and day prior to
the discontinuation of the parenteral anticoagulation therapy. You will have to
determine if there was any.
There is an Appendix and table for this 2.3 VTE parenteral therapy. When I’m reading
these I’m thinking this seems like so much but when you’re doing a chart like this and
working with a patient that has this, maybe it will flow better and be clearer. I think
just trying to mention it here with different data elements it seems overwhelming, but I
don’t think it will be that way when you’re doing this on a patient that’s in for that.
A monitoring documentation is a new data element. This one they want to know what
the physician, advanced practice nurse, physician assistant or pharmacist
documentation that intravenous unfractionated heparin and platelet counts were
managed by the fine parameters using nomogram or protocol to manage doses.
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Read the notes for abstraction. Pathways, orders or documentation that state that a
nomogram or protocol was used to calculate the U.S. age therapy dosage and
platelet count monitoring are acceptable. I think the thing to know here is both, there
are two things here. Managing the heparin and the platelet counts, have both to
answer yes.
There’s a new finding called ‘overlap therapy’. The question is, were parenteral
anticoagulation therapy and wafarin both administered on the same day or is a
reason documented for why both therapies weren’t initiated on the same day? So
your allowable value is yes they were both administered or no they weren’t and
there’s no documentation of a reason for not.
You have a patient refuses. You can select two. You have inclusion guidelines and
there are reasons for not administering the overlap. If the patient was having a
surgical procedure, had bleeding complications or were using a different oral
anticoagulant other than warfarin.
On page 283 there’s a table 2.3 VTE parenteral therapy table and then Appendix C
table 1.4 for warfarin therapy. I think for these new meds you are going to have to
look at these tables to become familiar with which medications are on there.
On page 284 is, what was the first date that parenteral anticoagulation therapy and
warfarin were both administered? I will let you read the notes for abstraction because
I think once you’re looking at a chart it will be easier to figure out if you’re going to
answer the yes, the no or what the date will be for that. I just wanted to point out
these new data elements for this measure.
Some of the things you need to be looking for, like this new one parenteral
anticoagulation end date. You’re looking for this kind of medication. What was the
last date that the parenteral anticoagulation medication was administered?
On page 288 again we’re talking about parenteral anticoagulation and now it’s like,
was it prescribed at discharge? With the prescribed at discharge it’s the same stuff,
the same instructions for all other meds at discharge like with aspirin and other things
we’ve mentioned.
I’m guessing you’re seeing a pattern. We have these new medications and we have
to pick up the date it was initiated. We have to pick up the date it was ended. If it was
discontinued or wasn’t given. That’s like where all these findings for these new data
elements around different medications, like I said were they given and if not the
reasons why they weren’t. Were they done at discharge and if not the reasons why
they weren’t. That’s what these new data elements appear to be.
On page 325, reason for discontinuation of parenteral therapy. Is there a reason
documented by the physician, APN PA or pharmacist for discontinuation of parenteral
therapy? The suggested data sources, only physician, APN or pharmacist
documentation are the reason. You can use nurses notes for patient refusal like in
the others.
On page 353, reason for no VTE prophylaxis ICU admission. Remember we had
our data elements for VTE prophylaxis for the ICU. Now it’s like okay is there
documentation why the VTE prophylaxis was not administered at the ICU admission
or transfer? It was given or if it wasn’t then why not? Here’s our instructions on if it
wasn’t given for the patient that was in the ICU.
This is another one where reasons for not giving, you need to read through the notes
for abstraction because this is where you have patients where there might be
documentation for them being low or minimal risk and then if you see that
terminology that can mean both pharmacological and mechanical don’t have to be
given.
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On page 354 it’s the same as we’ve talked about before. Patient or family refusal
may be documented by a nurse. It still has to be in the timeframe and patient or
family refusal of any form of prophylaxis you can select yes.
If you remember, before we had the finding of the oral factor XA inhibitor, this one
now is was there a reason for oral factor XA inhibitor ICU admission? If you have a
person who’s in ICU is there a reason why this medication was given?
On this one, only acceptable reasons identified in the list of inclusions no other
reasons will be accepted, so these were your reasons around the atrial fibrillation or
flutter or the hip or the knee surgeries. Those are the reasons why apparently that
this medication should be given.
For the VTE we have a couple surgical findings they’re asking for.
On page 413 surgical procedure… was a surgical procedure performed using
general or neuraxial anesthesia the day of or day after hospital admission? So you
have a timeframe. It doesn’t specify what kind of procedure or which one it says
general or neuraxial and if so than you will say yes.
On page 415 surgical procedure ICU admission… is there documentation that the
surgical procedure was performed using general or neuraxial anesthesia the day of
or day after ICU admission or transfer? It seems like they split up patients for this
VTE measure for those that were admitted or transferred to ICU, you’ll have your
certain data elements and then those that were not, have the same data elements
but not in ICU.
Again they’ve given you anesthesia guidelines not so much the procedure, so if a
procedure was performed using one of these anesthesia then you will select yes.
On page 406, so when it asks for surgical procedures then you have the question
about the end date of that procedure. It says on what date did the surgical procedure
end after ICU admission or transfer? On page 404 on what day did the surgical
procedure end after hospital admission? That’s for your patient who wasn’t in the ICU
it’s just a surgical end date.
Another new finding is unfractionated heparin UFH, was IV UFH administered? Yes
if it was and no if it wasn’t. Right there you’re given some inclusion guidelines for
other phrases they might use instead of the unfractionated heparin.
You have the data element VTE confirmed. This one is, is there documentation that
the patient had a diagnosis of VTE confirmed in one of the defined locations? You
need to read through the abstraction notes for this because we’re talking about VTE
diagnosis confirmed in certain locations.
We’re talking about during hospitalization. The first bullet says this data element does
include patients who are diagnosed with VTE on arrival or during the hospitalization.
On page 443 the last couple bullets. For patients with a low probability or test results
are inconclusive you’ll say no. For patients with a nuclear medicine V2 scan to rule
out PE, if the result was documented as high probability then you’ll select yes, for all
other impressions low probability intermediate then you’ll select no.
On page 444 if there’s conflicting information regarding whether the patient had a
VTE select no. So if the diagnostic test doesn’t confirm it but there’s documentation
saying it’s a VTE you’ll select no. You’ll note that halfway down on page 444 that this
list is all inclusive, so VTE locations are for confirmed. It’s defined as a VTE location
in the proximal leg veins, including the inferior vena cava, iliac, femoral or to
pulmonary emboli.
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So this data element does not apply to other sites of Venus Thrombosis unless
1:42:33 PE or DDT are also involved, then you have your exclusions. So VTE and
any of the exclusions there won’t be considered VTE confirmed.
On page 445 is diagnostic tests. Is there documentation that diagnostic tests for
VTE was performed relating to this hospitalization?
On page 446 is a list of all inclusive, so these are the tests you’re looking for. Were
one of those tests performed for VTE during this hospitalization?
On page 447 is VTE present at admission? Was there any documentation by the
physician APN PA that VTE was diagnosed or suspected on admission? Notes for
abstraction set the term on admission includes any documentation of a test to be
performed to rule out VTE or diagnosis or suspicion of VTE written from arrival to
admission date. You want to know if there was suspected or was the person
diagnosed with the VTE on admission.
On VTE prophylaxis status, this is another new data element. Was VTE prophylaxis
administered between the admission day and the day before the VTE diagnostic test
order date? What you’re looking for here on the notes for abstraction, to determine
the value for this data element the abstractor must locate the diagnostic test order
date and then review the chart to ascertain if VTE prophylaxis was administered
before the test was ordered. If any VTE prophylaxis was given within the specified
timeframe select value 1.
So you’ll have to look in to see when a diagnostic test was done and if they were
given any of the VTE prophylaxis administered between the day of admission and the
day before that test was done.
For this one there are a lot of instructions you want to look for where you can look the
allowable values and reasons for not administering, patient refusal for the nurse, the
different tests we talked about before what’s acceptable…
The last couple of findings are regarding warfarin.
On page 458, was wafarin administered during this hospitalization? That seems easy
to find out. If it was ordered then yes and if not then no.
On page 459, was warfarin prescribed at discharge? At discharge we’re looking for
the same thing as we do with all our meds.
I didn’t go through figuring out the population, but I think I would rather see if there
are any questions. I know I went fast and this was really just to point out the new data
elements around the VTE and stroke.
Mary Scott:
I have three questions. First, I did not follow where you were even talking about when
you first started so I missed that.
Robyn Carlson:
Regarding information on stroke for the population, you can find that would be in the
specifications manual, each clinical topic has its own section. At the beginning of the
section will tell you how to figure out your population.
Mary Scott:
I got the inference here for the VTE is that every patient we’re going to be doing this
on?
Robyn Carlson:
Yes.
Mary Scott:
So it’s like the immunization, the ED type thing?
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Robyn Carlson:
Right and I’m sorry when I started talking about the data elements I kind of forgot to
talk about the population.
Mary Scott:
I know there are three populations, ones that don’t have it, ones that do and then the
OB population.
Robyn Carlson:
Right, so when you look at the three different setups it’s going to virtually be where
everyone fits into one of those categories I believe.
Mary Scott:
The next question has to do with the written discharge instructions in regards to
warfarin, diet and that type of thing. I use a book put out by AHRQ on coumadin and
that includes the dietary considerations, keeping your appointments, side effects and
those types of things. If we document that this booklet has been reviewed and given
to the patient, is that sufficient or do each of those things have to be in separate
written instructions besides that booklet?
Robyn Carlson:
No. For any of the data elements of the discharge staff, if you’re given a pamphlet or
booklet you can’t just say given wafarin pamphlet or booklet you have to say given
booklet or pamphlet that includes information about etc. etc. If it says what they’re
looking for than it’s acceptable. You can just give the name and say it was given you
have to say given this booklet that contains this…
Mary Scott:
I hear you but it just makes it more difficult. Thank you.
Robyn Carlson:
Sure.
Julie Stevenson:
I have a couple questions too. My first is related to the VTE prophylaxis. It states that
prophylaxis that was administered the day of or day after hospital admission, does it
matter if they start out as observation like if they’re under observation on January 1
and then are admitted January 2, do we select the VTE prophylaxis starting with the
first day they arrive even though they call it hospital admission?
Robyn Carlson:
Yes it makes sense. Each data element is a little different so I don’t want to answer
off the top of my head. Could you email me that? We can have Mary send this out to
everyone who registered the answers.
Julie Stevenson:
That’d be great. Another question about the VTE present on admission… if the
patient comes into the ED and the ED doctor makes no note that he suspects a PE or
VTE but the admitting doctor in the H&P says rule out PE and orders a head CT, is
that good enough to say yes they had a VTE present on admission?
Robyn Carlson:
I’m going to say yes, but send this to me as well. When I was reading through the
notes it didn’t really give… like if they came through the ED it had to be… they made
it seem like they were a little more open as to on admission than some other… I will
check and get this answered and out to everyone as well.
Julie Stevenson:
Thank you.
Susan Nelson:
My question is regarding the VTE core measures also. I ran into a patient where the
test order date was today, but they had actually be started on heparin before they
went for the test, but the question asks about dates not times.
Robyn Carlson:
Okay I’d like to ask that you too send me your specific question to answer.
Susan Nelson:
Sure, no problem.
Connie T:
Hi Robyn, my question is, could you clarify the critical access hospitals do they have
to do the stroke measures and the VTE?
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Robyn Carlson:
At this time it’s not required for CMS and for this timeframe it hasn’t been required for
the state of Minnesota either. For right now starting with 1/1/13 discharges, no.
Again, I have to say I don’t know when the state might require it at some point and so
might CMS, but starting Jan 1 it’s not required.
Connie T:
Thank you.
Mary Jo Kyser:
Hi Robyn. I have a question related to reason for no VTE prophylaxis for a patient
that is at risk. We’re struggling with how to have it documented when the provider just
says it’s contra indicated mechanical and pharmacological is that sufficient
documentation or do they need a specific reason other than contra indicated or not
indicated?
Robyn Carlson:
Send this to me. When I was reading through these notes they seem to talk about it
being in terms of risk, like the wording being low risk or no risk and it seems like if
there was indication of no or low risk than it seems like that would be acceptable for
not giving both, but if those terms weren’t used than it seems like there had to be
specific reasons for that not being given.
Mary Jo Kyser:
I guess that’s my question specific reasons, can a provider just say assessed and a
patient is contra indicated to use pharmacological and mechanical?
Robyn Carlson:
I would want to check on that.
Mary Jo Kyser:
Thank you.
Robyn Carlson:
Before doing this I did go out on the site for questions and answers and didn’t find a
lot. I know when I’m going through this it’s not helpful for everyone to just read what
the notes for abstraction are, so I went to see if there were specific questions and
answers where I could say okay this is how they’re answering this or that and there
haven’t been a lot of questions / answers yet so we may be some of the first ones
trying to get answers on this stuff.
If it takes some time to get an answer it might be because they’re at the point now
where they’re trying to figure this out.
Bonnie Norris:
I’m sitting in for Derinda. Both of my questions are in regards to VTE confirmed. We
had a situation where a patient had a CT of the chest to rule out PE on admission,
which showed a filling defect likely representing a chronic PE. His reason for
admission was 1:57:20. That was the first time he was diagnosed with a PE and had
no prior knowledge of having one, would that be sufficient documentation to select
yes for VTE confirmed?
Robyn Carlson:
Could you send me this in an email since it’s so specific, where I can give you a
better response after looking at your documentation instead of answering just off the
top of my head.
Bonnie Norris:
Sure. The next one is similar.
Robyn Carlson:
Then send them both to me. These are situations others will probably have at times
so we can provide the right answers and send it out to everyone.
Bonnie Norris:
Great.
Robyn Carlson:
Let’s wrap up the call. If you have more questions send them to me and tell me they
are pertaining to this call then we can get the answers and get it out to everyone
who’s registered.
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Mary Montury:
I’ll send everyone an email after the call with a link to an evaluation for the call. If you
will participate that would be great.
Robyn Carlson:
Thank you everyone, again I apologize for the noise and going through kind of fast.
We’ll let everyone know when this is up on the website and remember if you have
any questions just send me an email or get a hold of Mary.
Thanks for staying on so long. Bye.
If you have any questions, contact Stratis Health at [email protected].
This material was prepared by Stratis Health, the Quality Improvement Organization for Minnesota, under a contract
with the Centers for Medicare & Medicaid Services (CMS), an agency of the US Department of Health and Human
Services. The contents presented do not necessarily reflect CMS policy.
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