+-----+-----------------------+----------+----------------------------+
| ad  | Does the medical      | \*1,2    | NPO = nothing by mouth     |
| mdc | record document the   |          |                            |
| npo | patient was kept NPO  | \*If 1,  | If the patient was kept    |
|     | for the entire        | go to    | NPO the entire             |
|     | hospital stay?        | k        | hospitalization and was    |
|     |                       | tconcom, | disch                      |
|     | 1\. Yes               | else go  | arged/transferred/deceased |
|     |                       | to       | NPO, answer "1." If the    |
|     | 2\. No                | scrdyspo | patient received any food, |
|     |                       |          | fluids, or medications by  |
|     |                       |          | mouth, answer "2."         |
|     |                       |          |                            |
|     |                       |          | Do not consider the        |
|     |                       |          | delivery of food, fluid,   |
|     |                       |          | or medication via a        |
|     |                       |          | nasogastric tube,          |
|     |                       |          | orogastric tube, or        |
|     |                       |          | percutaneous gastrostomy   |
|     |                       |          | tube as intake by mouth    |
|     |                       |          | (oral intake).             |
+-----+-----------------------+----------+----------------------------+
| ad  | Date of admission to  | mm       | **Auto-filled; can be      |
| mdt | inpatient care:       | /dd/yyyy | modified**                 |
|     |                       |          |                            |
|     |                       | **Auto   | A patient of a hospital is |
|     |                       | -filled: | considered an inpatient    |
|     |                       | can be   | upon issuance of written   |
|     |                       | mo       | doctors orders to that     |
|     |                       | dified** | effect.                    |
|     |                       |          |                            |
|     |                       |   --     | Exclusion: admission to    |
|     |                       | -------- | observation, arrival date  |
|     |                       |   \> =   |                            |
|     |                       |          |                            |
|     |                       | arrvdate |                            |
|     |                       |          |                            |
|     |                       | and \< = |                            |
|     |                       |          |                            |
|     |                       | leftdate |                            |
|     |                       |          |                            |
|     |                       |   --     |                            |
|     |                       | -------- |                            |
+-----+-----------------------+----------+----------------------------+
| ad  | Time of admission to  | \_\      | **Auto-filled; can be      |
| mtm | inpatient care:       | _\_\_\_\ | modified**                 |
|     |                       | UMT\     |                            |
|     |                       | **Auto   | Abstractor to verify       |
|     |                       | -filled: | admission time is correct. |
|     |                       | can be   | DO NOT use ER discharge    |
|     |                       | mo       | time or patient transfer   |
|     |                       | dified** | time.                      |
|     |                       |          |                            |
|     |                       |   ---    |                            |
|     |                       | -------- |                            |
|     |                       | -------- |                            |
|     |                       |   \> =   |                            |
|     |                       |   a      |                            |
|     |                       | rrvdate/ |                            |
|     |                       | arrvtime |                            |
|     |                       |          |                            |
|     |                       | and \< = |                            |
|     |                       |          |                            |
|     |                       | leftdate |                            |
|     |                       | /leftime |                            |
|     |                       |          |                            |
|     |                       |   ---    |                            |
|     |                       | -------- |                            |
|     |                       | -------- |                            |
+-----+-----------------------+----------+----------------------------+
| ar  | **Enter the           | mm       | **Arrival date is the      |
| rvd | earliest** documented | /dd/yyyy | earliest recorded date on  |
| ate | date the patient      |          | which the patient arrived  |
|     | arrived at acute care | Ab       | in the hospital's acute    |
|     | at this VAMC for this | stractor | care setting where care    |
|     | episode of care.      | may      | for acute ischemic stroke  |
|     |                       | enter    | could be most              |
|     |                       | 99       | appropriately provided**.  |
|     |                       | /99/9999 | Arrival date may differ    |
|     |                       | if       | from admission date. The   |
|     |                       | arrival  | intent of the arrival data |
|     |                       | date is  | elements is to capture the |
|     |                       | unable   | earliest date and time the |
|     |                       | to be    | patient was in this VAMC.  |
|     |                       | de       |                            |
|     |                       | termined | -   Do not include         |
|     |                       |          |     documentation from     |
|     |                       |   --     |     external sources,      |
|     |                       | -------- |     e.g., ambulance        |
|     |                       |   \<     |     records, clinic        |
|     |                       |  = admdt |     records, physician     |
|     |                       |          |     office record, or lab  |
|     |                       | and \< = |     reports, obtained      |
|     |                       |          |     prior to arrival       |
|     |                       | leftdate |     (unless pertinent to a |
|     |                       |          |     specific question).    |
|     |                       |   --     |     The intent is to       |
|     |                       | -------- |     utilize documentation  |
|     |                       |          |     that reflects          |
|     |                       |          |     processes that         |
|     |                       |          |     occurred in the ED or  |
|     |                       |          |     hospital.              |
|     |                       |          |                            |
|     |                       |          | -   If the patient was     |
|     |                       |          |     admitted for           |
|     |                       |          |     observation, and       |
|     |                       |          |     subsequently admitted  |
|     |                       |          |     to the unit or floor,  |
|     |                       |          |     use the date the       |
|     |                       |          |     patient arrived at the |
|     |                       |          |     hospital for           |
|     |                       |          |     observation.           |
|     |                       |          |                            |
|     |                       |          | -   If the patient is in   |
|     |                       |          |     an outpatient setting  |
|     |                       |          |     of the hospital (e.g., |
|     |                       |          |     undergoing dialysis,   |
|     |                       |          |     chemotherapy) and is   |
|     |                       |          |     subsequently admitted  |
|     |                       |          |     to the hospital, use   |
|     |                       |          |     the date the patient   |
|     |                       |          |     presents to the ED or  |
|     |                       |          |     arrives on the floor   |
|     |                       |          |     for inpatient care as  |
|     |                       |          |     the arrival date.      |
|     |                       |          |                            |
|     |                       |          | -   For "Direct Admits" to |
|     |                       |          |     the hospital, use the  |
|     |                       |          |     earliest date the      |
|     |                       |          |     patient arrived at the |
|     |                       |          |     hospital.              |
|     |                       |          |                            |
|     |                       |          | **ONLY ACCEPTABLE          |
|     |                       |          | SOURCES:** Any ED          |
|     |                       |          | documentation (includes ED |
|     |                       |          | vital sign record, ED      |
|     |                       |          | Outpatient Registration    |
|     |                       |          | form, triage record, ECG,  |
|     |                       |          | lab or x-ray reports,      |
|     |                       |          | etc., if these services    |
|     |                       |          | were rendered while the    |
|     |                       |          | patient was an ED          |
|     |                       |          | patient), nursing          |
|     |                       |          | admission assessment       |
|     |                       |          | /admitting note,           |
|     |                       |          | observation record,        |
|     |                       |          | procedure notes (such as   |
|     |                       |          | bronchoscopy, endoscopy),  |
|     |                       |          | vital signs graphic record |
|     |                       |          |                            |
|     |                       |          | Only enter 99/99/9999 if   |
|     |                       |          | the arrival date is unable |
|     |                       |          | to be determined from the  |
|     |                       |          | medical record             |
|     |                       |          | documentation.             |
+-----+-----------------------+----------+----------------------------+
| ar  | **Enter the           | \_       | **Arrival time is the      |
| rvt | earliest** documented | \_\_\_\_ | earliest recorded time the |
| ime | time the patient      |          | patient arrived in the     |
|     | arrived at acute care | UMT\     | hospital's acute care      |
|     | at this VAMC.         | **If     | setting where care for     |
|     |                       | unable   | acute ischemic stroke      |
|     |                       | to find  | could be most              |
|     |                       | the time | appropriately provided**.  |
|     |                       | of       | **Determine the earliest   |
|     |                       | arrival, | time the patient arrived   |
|     |                       | the      | at this VHA hospital, such |
|     |                       | ab       | as in the ED or            |
|     |                       | stractor | observation unit**.        |
|     |                       | can      |                            |
|     |                       | enter    | -   Do not include         |
|     |                       | 99:99**  |     documentation from     |
|     |                       |          |     external sources,      |
|     |                       |   --     |     e.g., ambulance        |
|     |                       | -------- |     records, clinic        |
|     |                       | -------- |     records, physician     |
|     |                       |          |     office record, or lab  |
|     |                       |  \< =adm |     reports, obtained      |
|     |                       | dt/admtm |     prior to arrival       |
|     |                       |          |     (unless pertinent to a |
|     |                       | and \< = |     specific question).    |
|     |                       |          |     The intent is to       |
|     |                       | leftdate |     utilize documentation  |
|     |                       | /leftime |     that reflects          |
|     |                       |          |     processes that         |
|     |                       |   --     |     occurred in the ED or  |
|     |                       | -------- |     hospital.              |
|     |                       | -------- |                            |
|     |                       |          | ```{=html}                 |
|     |                       |          | <!-- -->                   |
|     |                       |          | ```                        |
|     |                       |          | -   If the patient was     |
|     |                       |          |     admitted for           |
|     |                       |          |     observation, and       |
|     |                       |          |     subsequently admitted  |
|     |                       |          |     to the unit or floor,  |
|     |                       |          |     use the time the       |
|     |                       |          |     patient arrived at the |
|     |                       |          |     hospital for           |
|     |                       |          |     observation.           |
|     |                       |          |                            |
|     |                       |          | -   If the patient is in   |
|     |                       |          |     an outpatient setting  |
|     |                       |          |     of the hospital (e.g., |
|     |                       |          |     undergoing dialysis,   |
|     |                       |          |     chemotherapy) and is   |
|     |                       |          |     subsequently admitted  |
|     |                       |          |     to the hospital, use   |
|     |                       |          |     the time the patient   |
|     |                       |          |     presents to the ED or  |
|     |                       |          |     arrives on the floor   |
|     |                       |          |     for inpatient care as  |
|     |                       |          |     the arrival time.      |
|     |                       |          |                            |
|     |                       |          | -   For "Direct Admits" to |
|     |                       |          |     the hospital, use the  |
|     |                       |          |     earliest time the      |
|     |                       |          |     patient arrived at the |
|     |                       |          |     hospital.              |
|     |                       |          |                            |
|     |                       |          | **ONLY ACCEPTABLE          |
|     |                       |          | SOURCES:** Any ED          |
|     |                       |          | documentation (includes ED |
|     |                       |          | vital sign record, ED      |
|     |                       |          | Outpatient Registration    |
|     |                       |          | form, triage record, ECG,  |
|     |                       |          | lab or x-ray reports,      |
|     |                       |          | etc., if these services    |
|     |                       |          | were rendered while the    |
|     |                       |          | patient was an ED          |
|     |                       |          | patient), nursing          |
|     |                       |          | admission assessment       |
|     |                       |          | /admitting note,           |
|     |                       |          | observation record,        |
|     |                       |          | procedure notes (such as   |
|     |                       |          | bronchoscopy, endoscopy),  |
|     |                       |          | vital signs graphic record |
|     |                       |          |                            |
|     |                       |          | **If unable to determine   |
|     |                       |          | the time of arrival, enter |
|     |                       |          | default time 99:99.**      |
+-----+-----------------------+----------+----------------------------+
| as  | Does the medical      | 1,2      | The Morse Fall Scale (MFS) |
| esf | record document the   |          | is comprised of six        |
| all | Morse Fall Scale was  | If 2,    | subscales used to assess a |
|     | completed on day 1 or | a        | patient's fall risk        |
|     | 2 of this admission?  | uto-fill | factors. The MFS assesses  |
|     |                       | falldt   | the patient's history of   |
|     |                       | as       | falling (immediate or      |
|     |                       | 99/      | within past 3 months),     |
|     |                       | 99/9999, | secondary diagnosis,       |
|     |                       | falltm   | ambulatory aid, IV/heparin |
|     |                       | as       | lock, gait/transferring,   |
|     |                       | 99:99,   | and mental status.         |
|     |                       | and      |                            |
|     |                       | morscore | Count the day of arrival   |
|     |                       | as zzz,  | as hospital day 1.         |
|     |                       | and go   |                            |
|     |                       | to       |                            |
|     |                       | brad1dt  |                            |
+-----+-----------------------+----------+----------------------------+
| as  | ###### Was            | 1,2,99   | **The NIH Stroke Scale     |
| ses | the severity of the s |          | (NIHSS) is a well          |
| evl | troke assessed using  | If       | established, 11-item       |
|     | the NIH Stroke Scale? | assesev1 | clinical evaluation        |
| as  |                       | = -1 or  | instrument that is used to |
| ses | **Indicate all that   | assesev2 | measure stroke severity.** |
| ev2 | apply:**              | = -1, go |                            |
|     |                       | to       | **A NIHSS completed by a   |
| ass | 1\. NIH Stroke Scale  | nihssdt  | physician, APN, PA, or RN  |
| ese | documented as a       |          | is acceptable.**           |
| v99 | composite number of   | If       |                            |
|     | the individual scores | a        | **Option 1 = composite     |
|     |                       | ssesev2, | (total) score documented   |
|     | 2\. NIH Stroke Scale  | a        | in the record**            |
|     | documented by         | uto-fill |                            |
|     | individual components | entrsum  | **Option 2 = individual    |
|     |                       | as zz    | components documented      |
|     | 99\. no assessment by |          | without composite score**  |
|     | NIH Stroke Scale      | If 99,   |                            |
|     |                       | a        | **Option 99 = the formal   |
|     |                       | uto-fill | NIHSS composite score or   |
|     |                       | nihssdt  | individual components are  |
|     |                       | as       | not documented in the      |
|     |                       | 99/      | record**                   |
|     |                       | 99/9999, |                            |
|     |                       | nihsstm  |                            |
|     |                       | as       |                            |
|     |                       | 99:99,   |                            |
|     |                       | entrsum  |                            |
|     |                       | as zzand |                            |
|     |                       |          |                            |
|     |                       | go to    |                            |
|     |                       | loc      |                            |
|     |                       |          |                            |
|     |                       | **99     |                            |
|     |                       | cannot   |                            |
|     |                       | be       |                            |
|     |                       | entered  |                            |
|     |                       | with any |                            |
|     |                       | other    |                            |
|     |                       | number** |                            |
+-----+-----------------------+----------+----------------------------+
| b   | # Enter the           | #        | **Episode of care can      |
| rad | date the [first]{.und |          | begin up to 24 hours prior |
| 1dt | erline} Braden Scale  | # mm     | to admission (Examples:    |
|     | was completed during  | /dd/yyyy | patient admission to an    |
|     | this episode of care. |          | observation bed, surgery   |
|     |                       | **Ab     | in the ambulatory setting, |
|     |                       | stractor | patient held in ED         |
|     |                       | can      | awaiting bed.)**           |
|     |                       | enter    |                            |
|     |                       | 99       | **Do not include a Braden  |
|     |                       | /99/9999 | Scale done in the NHCU.**  |
|     |                       | if no    |                            |
|     |                       | Braden   | **If no Braden Scale was   |
|     |                       | Scale    | done during the entire     |
|     |                       | done     | episode of care, enter     |
|     |                       | during   | 99/99/9999.**              |
|     |                       | entire   |                            |
|     |                       | episode  | **Documentation in the     |
|     |                       | of       | record must reference the  |
|     |                       | care**   | Braden Scale or Braden     |
|     |                       |          | Risk Scale. No other skin  |
|     |                       | If       | assessment tool is         |
|     |                       | 99/      | acceptable.**              |
|     |                       | 99/9999, |                            |
|     |                       | a        | The Braden Scale is a      |
|     |                       | uto-fill | rating scale used to       |
|     |                       | brad1tm  | predict pressure ulcer     |
|     |                       | as       | risk. Scores for the       |
|     |                       | 99:99,   | Braden Scale range from 6  |
|     |                       | frstbrad | to 23. A lower score       |
|     |                       | as 95    | indicates a lower level of |
|     |                       |          | a patient's ability to     |
|     |                       |   --     | function.                  |
|     |                       | -------- |                            |
|     |                       |          | A score of \<= 18 places   |
|     |                       |  \< = 24 | the patient at risk for    |
|     |                       |   hours  | pressure ulcer             |
|     |                       |          | development. The lower the |
|     |                       | prior to | score the higher the risk  |
|     |                       |   or     | for pressure ulcer         |
|     |                       |  = admdt | development.               |
|     |                       |          |                            |
|     |                       |  and \<= |                            |
|     |                       |          |                            |
|     |                       | leftdate |                            |
|     |                       |          |                            |
|     |                       |   --     |                            |
|     |                       | -------- |                            |
+-----+-----------------------+----------+----------------------------+
| b   | # Enter the           | \_       | Time must be entered in    |
| rad | time the first Braden | \_\_\_\_ | Universal Military Time.   |
| 1tm |  Scale was completed. |          |                            |
|     |                       | UMT      | **Enter the time           |
|     |                       |          | documentation of the       |
|     |                       | Will be  | Braden Scale note was      |
|     |                       | aut      | completed and signed.**    |
|     |                       | o-filled |                            |
|     |                       | as 99:99 | A Braden scale may be      |
|     |                       | if       | completed prior to formal  |
|     |                       | brad1dt  | admission. The software    |
|     |                       | =        | will allow entry of a date |
|     |                       | 99       | and time within 24 hours   |
|     |                       | /99/9999 | prior to date of formal    |
|     |                       |          | admission.                 |
|     |                       | <table>  |                            |
|     |                       | <c       |                            |
|     |                       | olgroup> |                            |
|     |                       | <col     |                            |
|     |                       | style=   |                            |
|     |                       | "width:  |                            |
|     |                       | 100%" /> |                            |
|     |                       | </c      |                            |
|     |                       | olgroup> |                            |
|     |                       | <tbody>  |                            |
|     |                       | <tr      |                            |
|     |                       | clas     |                            |
|     |                       | s="odd"> |                            |
|     |                       | <td      |                            |
|     |                       | ><p>&lt; |                            |
|     |                       | = 24     |                            |
|     |                       | hours    |                            |
|     |                       | prior    |                            |
|     |                       | to or    |                            |
|     |                       | &gt;     |                            |
|     |                       | a        |                            |
|     |                       | dmtm</p> |                            |
|     |                       | <p>If    |                            |
|     |                       | brad1dt  |                            |
|     |                       | =        |                            |
|     |                       | l        |                            |
|     |                       | eftdate, |                            |
|     |                       | &lt;     |                            |
|     |                       | leftime< |                            |
|     |                       | /p></td> |                            |
|     |                       | </tr>    |                            |
|     |                       | </tbody> |                            |
|     |                       | </table> |                            |
+-----+-----------------------+----------+----------------------------+
| co  | Is there              | 1,2      | **Disregard documentation  |
| mfo | documentation by a    |          | of comfort measures only   |
| nly | physician, APN, or PA | If 2,    | (palliative care, hospice, |
|     | of comfort measures   | a        | etc.) written on the day   |
|     | only during the       | uto-fill | of discharge in any source |
|     | hospital stay?        | comfordt | other than discharge       |
|     |                       | as       | summary OR when it is      |
|     |                       | 99       | referring to care planned  |
|     |                       | /99/9999 | after discharge only.**    |
|     |                       |          |                            |
|     |                       |          | **If DNR-CC is documented, |
|     |                       |          | enter "2" unless there is  |
|     |                       |          | documented clarification   |
|     |                       |          | that CC stands for         |
|     |                       |          | "comfort care."**          |
|     |                       |          |                            |
|     |                       |          | **Only accept terms        |
|     |                       |          | identified in the list of  |
|     |                       |          | inclusions. No other       |
|     |                       |          | terminology will be        |
|     |                       |          | accepted.** If any of the  |
|     |                       |          | inclusions are documented, |
|     |                       |          | select "1" regardless of   |
|     |                       |          | other documentation.       |
|     |                       |          |                            |
|     |                       |          | +----------+-----------+   |
|     |                       |          | | **Inc    | **Ex      |   |
|     |                       |          | | lusion** | clusion** |   |
|     |                       |          | +----------+-----------+   |
|     |                       |          | | Comfort  | Chemical  |   |
|     |                       |          | | care     | code only |   |
|     |                       |          | +----------+-----------+   |
|     |                       |          | | Comfort  | Do not    |   |
|     |                       |          | | measures | c         |   |
|     |                       |          | |          | ardiovert |   |
|     |                       |          | +----------+-----------+   |
|     |                       |          | | Comfort  | Do not    |   |
|     |                       |          | | measures | def       |   |
|     |                       |          | | only     | ibrillate |   |
|     |                       |          | | (CMO)    |           |   |
|     |                       |          | +----------+-----------+   |
|     |                       |          | | Comfort  | Do not    |   |
|     |                       |          | | only     | intubate  |   |
|     |                       |          | |          | (DNI)     |   |
|     |                       |          | +----------+-----------+   |
|     |                       |          | | End of   | Do Not    |   |
|     |                       |          | | life     | Re        |   |
|     |                       |          | | care     | suscitate |   |
|     |                       |          | |          | (DNR)     |   |
|     |                       |          | +----------+-----------+   |
|     |                       |          | | Hospice  | Keep      |   |
|     |                       |          | |          | co        |   |
|     |                       |          | |          | mfortable |   |
|     |                       |          | +----------+-----------+   |
|     |                       |          | | Hospice  | Living    |   |
|     |                       |          | | care     | Will      |   |
|     |                       |          | +----------+-----------+   |
|     |                       |          | | Pa       | No        |   |
|     |                       |          | | lliative | a         |   |
|     |                       |          | | care     | ggressive |   |
|     |                       |          | |          | treatment |   |
|     |                       |          | +----------+-----------+   |
|     |                       |          | | Terminal | No        |   |
|     |                       |          | | care     | antia     |   |
|     |                       |          | |          | rrhythmic |   |
|     |                       |          | |          | therapy   |   |
|     |                       |          | +----------+-----------+   |
|     |                       |          | | Physicia | No        |   |
|     |                       |          | | n/APN/PA | a         |   |
|     |                       |          | | docum    | rtificial |   |
|     |                       |          | | entation | res       |   |
|     |                       |          | | of       | pirations |   |
|     |                       |          | | comfort  |           |   |
|     |                       |          | | measures | No        |   |
|     |                       |          | | only     | cardiac   |   |
|     |                       |          | | m        | m         |   |
|     |                       |          | | entioned | onitoring |   |
|     |                       |          | | in the   |           |   |
|     |                       |          | | f        | No        |   |
|     |                       |          | | ollowing | Cardio    |   |
|     |                       |          | | content  | pulmonary |   |
|     |                       |          | | is       | Resu      |   |
|     |                       |          | | acc      | scitation |   |
|     |                       |          | | eptable: |           |   |
|     |                       |          | | comfort  | (NCR)     |   |
|     |                       |          | | measures |           |   |
|     |                       |          | | only     | No chest  |   |
|     |                       |          | | recomme  | com       |   |
|     |                       |          | | ndation, | pressions |   |
|     |                       |          | | order    |           |   |
|     |                       |          | | for      | No code   |   |
|     |                       |          | | consult  |           |   |
|     |                       |          | | ation/ev | No Code   |   |
|     |                       |          | | aluation | 99        |   |
|     |                       |          | | by       |           |   |
|     |                       |          | | ho       | No CPR    |   |
|     |                       |          | | spice/pa |           |   |
|     |                       |          | | lliative | No heroic |   |
|     |                       |          | | care,    | or        |   |
|     |                       |          | | patien   | a         |   |
|     |                       |          | | t/family | ggressive |   |
|     |                       |          | | request  | measures  |   |
|     |                       |          | | for      |           |   |
|     |                       |          | | comfort  | No        |   |
|     |                       |          | | measures | i         |   |
|     |                       |          | | only,    | ntubation |   |
|     |                       |          | | referral | and/or    |   |
|     |                       |          | | to       | ve        |   |
|     |                       |          | | ho       | ntilation |   |
|     |                       |          | | spice/pa |           |   |
|     |                       |          | | lliative | No        |   |
|     |                       |          | | care     | invasive  |   |
|     |                       |          | | service. | p         |   |
|     |                       |          | |          | rocedures |   |
|     |                       |          | |          |           |   |
|     |                       |          | |          | No other  |   |
|     |                       |          | |          | protocols |   |
|     |                       |          | |          | a         |   |
|     |                       |          | |          | ssociated |   |
|     |                       |          | |          | with      |   |
|     |                       |          | |          | advanced  |   |
|     |                       |          | |          | cardiac   |   |
|     |                       |          | |          | life      |   |
|     |                       |          | |          | support   |   |
|     |                       |          | |          |           |   |
|     |                       |          | |          | No        |   |
|     |                       |          | |          | resu      |   |
|     |                       |          | |          | scitative |   |
|     |                       |          | |          | me        |   |
|     |                       |          | |          | dications |   |
|     |                       |          | |          |           |   |
|     |                       |          | |          | No        |   |
|     |                       |          | |          | resu      |   |
|     |                       |          | |          | scitative |   |
|     |                       |          | |          | measures  |   |
|     |                       |          | |          | (NRM)     |   |
|     |                       |          | |          |           |   |
|     |                       |          | |          | No        |   |
|     |                       |          | |          | vas       |   |
|     |                       |          | |          | opressors |   |
|     |                       |          | |          |           |   |
|     |                       |          | |          | S         |   |
|     |                       |          | |          | upportive |   |
|     |                       |          | |          | care      |   |
|     |                       |          | +----------+-----------+   |
+-----+-----------------------+----------+----------------------------+
| co  | Enter the date of the | mm       | Enter the exact date. The  |
| mfo | first documentation   | /dd/yyyy | use of 01 to indicate      |
| rdt | of comfort measures   |          | missing month or day is    |
|     | only.                 | Will be  | not acceptable.            |
|     |                       | aut      |                            |
|     |                       | o-filled |                            |
|     |                       | as       |                            |
|     |                       | 99       |                            |
|     |                       | /99/9999 |                            |
|     |                       | if       |                            |
|     |                       |          |                            |
|     |                       | comfonly |                            |
|     |                       | = 2      |                            |
|     |                       |          |                            |
|     |                       |   --     |                            |
|     |                       | -------- |                            |
|     |                       |   \      |                            |
|     |                       | >= admdt |                            |
|     |                       |          |                            |
|     |                       |  and \<= |                            |
|     |                       |          |                            |
|     |                       | leftdate |                            |
|     |                       |          |                            |
|     |                       |   --     |                            |
|     |                       | -------- |                            |
+-----+-----------------------+----------+----------------------------+
| co  | Did the               | 1,2,     | **To determine the end of  |
| nth | physician/APN/PA      | 95,98,99 | hospital day two, count    |
| rom | document a reason for |          | the arrival date as        |
|     | not administering     | Will be  | hospital day one.**        |
|     | antithrombotic        | aut      | Reasons for not            |
|     | therapy by the end of | o-filled | prescribing antithrombotic |
|     | hospital day 2?       | as 95 if | therapy must be documented |
|     |                       | any      | by a physician, APN, or    |
|     | (Aspirin,             | wicthrom | PA. If reasons are not     |
|     | ASA/dipyridamole,     | (except  | mentioned in the context   |
|     | Aggrenox, warfarin,   | wi       | of antithrombotics, do not |
|     | clopidogrel, Plavix,  | cthrom6) | make inferences (e.g., do  |
|     | ticlopidine, Ticlid,  | = 1      | not assume antithrombotics |
|     | heparin, low          |          | are not being prescribed   |
|     | molecular weight      |          | because of a bleeding      |
|     | heparin, or           |          | disorder unless the        |
|     | alternative           |          | documentation explicitly   |
|     | anticoagulants)       |          | links the bleeding         |
|     |                       |          | disorder to not            |
|     | 1\. Yes               |          | prescribing antithrombotic |
|     |                       |          | therapy).                  |
|     | 2\. No                |          |                            |
|     |                       |          | Examples of reasons not to |
|     | 95\. Not applicable   |          | administer antithrombotic  |
|     |                       |          | therapy include but are    |
|     | 98\. Patient refused  |          | not limited to:            |
|     | antithrombotic        |          |                            |
|     | medications           |          | -   Allergy to ALL         |
|     |                       |          |     antithrombotic therapy |
|     | 99\. Unable to        |          |                            |
|     | determine             |          | -   Aortic dissection,     |
|     |                       |          |     current                |
|     |                       |          |                            |
|     |                       |          | -   Bleeding disorder      |
|     |                       |          |                            |
|     |                       |          | -   Brain/CNS cancer       |
|     |                       |          |                            |
|     |                       |          | -   CVA/hemorrhage         |
|     |                       |          |                            |
|     |                       |          | -   Extensive/metastatic   |
|     |                       |          |     cancer                 |
|     |                       |          |                            |
|     |                       |          | -   Hemorrhage, any type   |
|     |                       |          |                            |
|     |                       |          | -   Intracranial           |
|     |                       |          |     surgery/biopsy         |
|     |                       |          |                            |
|     |                       |          | -   Peptic ulcer, current  |
|     |                       |          |                            |
|     |                       |          | -   Planned surgery within |
|     |                       |          |     7 days of discharge    |
|     |                       |          |                            |
|     |                       |          | -   Risk or bleeding,      |
|     |                       |          |     current                |
|     |                       |          |                            |
|     |                       |          | -   Unrepaired             |
|     |                       |          |     intracranial aneurysm  |
|     |                       |          |                            |
|     |                       |          | Suggested sources:         |
|     |                       |          | Admission H&P, progress    |
|     |                       |          | notes, consultation        |
|     |                       |          | reports, discharge summary |
+-----+-----------------------+----------+----------------------------+
| dc  | Did the               | 1,2,3,95 | Discharge instructions for |
| doc | patient/caregiver     |          | follow-up must indicate    |
| apt | receive written       | Will be  | that the follow-up is to   |
|     | educational materials | aut      | be with one of the         |
|     | regarding follow-up   | o-filled | designated health care     |
|     | after discharge?      | as 3, if | providers or in an office  |
|     |                       | dcdocems | or clinic setting.         |
|     | 1\. Yes               | = 3      | Follow-up in a disease or  |
|     |                       |          | case management program is |
|     | 2\. No                |          | acceptable. Instructions   |
|     |                       |          | to call for an appointment |
|     | 3\. No, documented    |          | or other follow-up is also |
|     | the patient is unable |          | acceptable. Follow-up for  |
|     | to comprehend AND no  |          | ancillary service only,    |
|     | caregiver is present  |          | e.g. lab, radiology, etc.  |
|     |                       |          | is not sufficient.         |
|     | 95\. Not applicable   |          |                            |
|     |                       |          | Videos, CDs, and DVDs are  |
|     |                       |          | acceptable for educational |
|     |                       |          | material if there is clear |
|     |                       |          | documentation that         |
|     |                       |          | follow-up instructions     |
|     |                       |          | were included in the       |
|     |                       |          | material **and** the       |
|     |                       |          | patient was given a copy   |
|     |                       |          | to take home.              |
+-----+-----------------------+----------+----------------------------+
| dc  | Did the               | 1,2,3,95 | The educational material   |
| doc | patient/caregiver     |          | must include instructions  |
| ems | receive written       | If 3,    | to activate EMS (e.g.,     |
|     | educational materials | a        | call 911) if signs or      |
|     | regarding the need    | uto-fill | symptoms of stroke occur.  |
|     | for activation of the | r        | The intent is to educate   |
|     | emergency medical     | emaining | patients not to delay      |
|     | system (EMS) if signs | q        | seeking immediate medical  |
|     | or symptoms of stroke | uestions | attention when             |
|     | occur?                | as 3,    | signs/symptoms of stroke   |
|     |                       | and go   | occur or stroke is         |
|     | 1\. Yes               | to       | suspected. Documentation   |
|     |                       | dcmeds   | must include Videos, CDs,  |
|     | 2\. No                |          | and DVDs are acceptable    |
|     |                       |          | for educational material   |
|     | 3\. No, documented    |          | if there is clear          |
|     | the patient is unable |          | documentation that         |
|     | to comprehend AND no  |          | follow-up instructions     |
|     | caregiver is present  |          | were included in the       |
|     |                       |          | material **and** the       |
|     | 95\. Not applicable   |          | patient was given a copy   |
|     |                       |          | to take home.              |
+-----+-----------------------+----------+----------------------------+
| dc  | Did the               | 1,2,3,95 | Instructions must include  |
| doc | patient/caregiver     |          | at least the names of all  |
| med | receive written       | Will be  | discharge medications.     |
|     | educational materials | aut      | Specific names are not     |
|     | regarding medications | o-filled | required for laxatives,    |
|     | prescribed?           | as 3, if | antacids, vitamins, herbs, |
|     |                       | dcdocems | or prn (as needed)         |
|     | 1\. Yes               | = 3      | medications. Oxygen is not |
|     |                       |          | considered a medication.   |
|     | 2\. No                |          |                            |
|     |                       |          | **The patient must receive |
|     | 3\. No, documented    |          | a written list of all      |
|     | the patient is unable |          | his/her discharge          |
|     | to comprehend AND no  |          | medications, and the       |
|     | caregiver is present  |          | record should contain      |
|     |                       |          | evidence the patient was   |
|     | 95\. Not applicable   |          | educated regarding these   |
|     |                       |          | medications.**             |
|     |                       |          |                            |
|     |                       |          | **The best source of a     |
|     |                       |          | patient's discharge        |
|     |                       |          | medications is the         |
|     |                       |          | pharmacy discharge         |
|     |                       |          | medication list.**         |
|     |                       |          |                            |
|     |                       |          | -   In cases where there   |
|     |                       |          |     is a medication in one |
|     |                       |          |     source that is not     |
|     |                       |          |     mentioned in another   |
|     |                       |          |     source, it should be   |
|     |                       |          |     interpreted as a       |
|     |                       |          |     discharge medication   |
|     |                       |          |     unless documentation   |
|     |                       |          |     suggests that it was   |
|     |                       |          |     NOT prescribed at      |
|     |                       |          |     discharge. **Consider  |
|     |                       |          |     it a discharge         |
|     |                       |          |     medication in the      |
|     |                       |          |     absence of             |
|     |                       |          |     contradictory          |
|     |                       |          |     documentation**.       |
|     |                       |          |                            |
|     |                       |          | -   If conflicting         |
|     |                       |          |     documentation raises   |
|     |                       |          |     enough questions after |
|     |                       |          |     careful examination of |
|     |                       |          |     circumstances, the     |
|     |                       |          |     case should be deemed  |
|     |                       |          |     unable to determine    |
|     |                       |          |     and answered as "2."   |
|     |                       |          |                            |
|     |                       |          | -   If a medication is     |
|     |                       |          |     listed as a discharge  |
|     |                       |          |     medication, consider   |
|     |                       |          |     the medication to be a |
|     |                       |          |     discharge medication   |
|     |                       |          |     unless contradictory   |
|     |                       |          |     documentation exists.  |
|     |                       |          |     If a medication is not |
|     |                       |          |     listed as a discharge  |
|     |                       |          |     medication and there   |
|     |                       |          |     is only documentation  |
|     |                       |          |     of a plan to delay     |
|     |                       |          |     initiation/restarting  |
|     |                       |          |     of a medication for a  |
|     |                       |          |     time period after      |
|     |                       |          |     discharge, select "2." |
|     |                       |          |                            |
|     |                       |          | Videos, CDs, and DVDs are  |
|     |                       |          | acceptable for educational |
|     |                       |          | material only if there is  |
|     |                       |          | clear documentation that   |
|     |                       |          | **all** the names of the   |
|     |                       |          | **patient's specific       |
|     |                       |          | discharge medications were |
|     |                       |          | included** in the material |
|     |                       |          | **and** the patient was    |
|     |                       |          | given a copy to take home. |
+-----+-----------------------+----------+----------------------------+
| dc  | Did the               | 1,2,3,95 | **Personal risk factors    |
| doc | patient/caregiver     |          | for stroke may include but |
| rsk | receive written       | Will be  | are not limited to: high   |
|     | educational materials | aut      | blood pressure, elevated   |
|     | regarding personal    | o-filled | cholesterol, diabetes,     |
|     | risk factors for      | as 3, if | overweight (BMI \>=25),    |
|     | stroke?               | dcdocems | physical inactivity,       |
|     |                       | = 3      | excessive alcohol          |
|     | 1\. Yes               |          | consumption, carotid       |
|     |                       |          | artery stenosis, atrial    |
|     | 2\. No                |          | fibrillation, smoking. The |
|     |                       |          | written discharge          |
|     | 3\. No, documented    |          | instructions must address  |
|     | the patient is unable |          | risk factors for stroke.** |
|     | to comprehend AND no  |          |                            |
|     | caregiver is present  |          | Videos, CDs, and DVDs are  |
|     |                       |          | acceptable for educational |
|     | 95\. Not applicable   |          | material only if there is  |
|     |                       |          | clear documentation that   |
|     |                       |          | risk factors for stroke    |
|     |                       |          | **were included** in the   |
|     |                       |          | material **and** the       |
|     |                       |          | patient was given a copy   |
|     |                       |          | to take home.              |
+-----+-----------------------+----------+----------------------------+
| dcd | Did the               | 1,2,3,95 | **Examples of stroke       |
| ocw | patient/caregiver     |          | warning signs may include, |
| arn | receive written       | Will be  | but are not limited to:**  |
|     | educational materials | aut      |                            |
|     | regarding the warning | o-filled | -   **Sudden numbness or   |
|     | signs and symptoms of | as 3, if |     weakness of the face,  |
|     | stroke?               | dcdocems |     arm or leg, especially |
|     |                       | = 3      |     on one side of the     |
|     | 1\. Yes               |          |     body**                 |
|     |                       |          |                            |
|     | 2\. No                |          | -   **Sudden confusion,    |
|     |                       |          |     trouble speaking or    |
|     | 3\. No, documented    |          |     understanding**        |
|     | the patient is unable |          |                            |
|     | to comprehend AND no  |          | -   **Sudden trouble       |
|     | caregiver is present  |          |     seeing in one or both  |
|     |                       |          |     eyes**                 |
|     | 95\. Not applicable   |          |                            |
|     |                       |          | -   **Sudden trouble       |
|     |                       |          |     walking, dizziness,    |
|     |                       |          |     loss of balance or     |
|     |                       |          |     coordination**         |
|     |                       |          |                            |
|     |                       |          | -   **Sudden severe        |
|     |                       |          |     headache with no know  |
|     |                       |          |     cause**                |
|     |                       |          |                            |
|     |                       |          | Videos, CDs, and DVDs are  |
|     |                       |          | acceptable for educational |
|     |                       |          | material only if there is  |
|     |                       |          | clear documentation that   |
|     |                       |          | warning signs and symptoms |
|     |                       |          | for stroke **were          |
|     |                       |          | included** in the material |
|     |                       |          | **and** the patient was    |
|     |                       |          | given a copy to take home. |
+-----+-----------------------+----------+----------------------------+
| dc  | Were any of the       |          | **Select "1" for each      |
| thr | following medications |          | medication prescribed at   |
| om1 | prescribed at         |          | discharge.**               |
|     | discharge?            |          |                            |
| dc  |                       |          | **3 = Warfarin** such as:  |
| asa | <table>               |          | Coumadin, Jantoven,        |
| dos | <colgroup>            |          | Panwarfin, Warfilone       |
|     | <col                  |          |                            |
| dc  | style="width: 38%" /> |          | **6 = Low dose             |
| thr | <col                  |          | unfractionated heparin**   |
| om2 | style="width: 26%" /> |          | (LDUH) -- **only include   |
|     | <col                  |          | heparin administered by    |
| dc  | style="width: 18%" /> |          | [subcutaneous]{.underline} |
| thr | <col                  |          | route** (SC, SQ, SubQ)     |
| om3 | style="width: 17%" /> |          | LDUH such as: heparin,     |
|     | </colgroup>           |          | calcilean, calciparine     |
| dc  | <tbody>               |          |                            |
| thr | <tr class="odd">      |          | **7 = Intravenous          |
| om4 | <td></td>             |          | heparin**                  |
|     | <td><strong>Field     |          |                            |
| dc  | Format</strong></td>  |          | **8 = Low molecular weight |
| thr | <td><stro             |          | heparin** (LMWH) such as:  |
| om5 | ng>Dose</strong></td> |          | enoxaparin (Lovenox),      |
|     | <td><p><strong>F      |          | fragmin, innohep           |
| dc  | requency</strong></p> |          |                            |
| thr | <p                    |          | **9 = Alternative          |
| om6 | >1,2,3,95,99</p></td> |          | anticoagulants** such as   |
|     | </tr>                 |          | danaparoid (Organon),      |
| d   | <tr class="even">     |          | hirudin (Lepirudin),       |
| cun | <td>1. Aspirin</td>   |          | bivalirudin (Angiomax),    |
| hep | <td><p><st            |          | other heparinoids          |
|     | rong>1,2</strong></p> |          |                            |
| dc  | <p><strong>If 2,      |          | **[Dose and frequency of   |
| hep | auto-fill dcasados    |          | admi                       |
| fre | as                    |          | nistration:]{.underline}** |
|     | z                     |          |                            |
| dc  | zzz</strong></p></td> |          | -   **Aspirin = If more    |
| thr | <td><p><strong>_ _    |          |     than one dose of       |
| om7 | _</strong></p>        |          |     aspirin is             |
|     | <table>               |          |     administered by the    |
| dc  | <colgroup>            |          |     end of hospital day    |
| thr | <col                  |          |     two, enter the largest |
| om8 | s                     |          |     dose.** For example,   |
|     | tyle="width: 100%" /> |          |     if ASA 81mg is given   |
| dc  | </colgroup>           |          |     on day 1 and 325 mg is |
| lmh | <tbody>               |          |     given on day 2, enter  |
| dos | <tr class="odd">      |          |     325 mg. Aspirin is     |
|     | <td>&gt; 0 and &lt;   |          |     prescribed as          |
| dc  | 999</td>              |          |     milligrams (mg). Dose  |
| lmh | </tr>                 |          |     range may vary from 50 |
| fre | </tbody>              |          |     to 325 mg.             |
|     | </table></td>         |          |                            |
| dc  | <td></td>             |          | -   **Low dose             |
| thr | </tr>                 |          |     unfractionated         |
| om9 | <tr class="odd">      |          |     heparin(subQ only) =   |
|     | <td>2.                |          |     prescribed as units.** |
|     | ASA/dipyridamole      |          |     If the low dose        |
|     | (Aggrenox)</td>       |          |     unfractionated heparin |
|     | <td><str              |          |     is ordered to be given |
|     | ong>1,2</strong></td> |          |     more than once a day,  |
|     | <td></td>             |          |     enter the units        |
|     | <td></td>             |          |     ordered per dose. For  |
|     | </tr>                 |          |     example, Heparin 5000  |
|     | <tr class="even">     |          |     units subQ bid. Enter  |
|     | <td>3. Warfarin       |          |     5000 for the dose.     |
|     | (Coumadin)</td>       |          |                            |
|     | <td><str              |          |     -   **Enter the number |
|     | ong>1,2</strong></td> |          |         of times a day the |
|     | <td></td>             |          |         low dose subQ      |
|     | <td></td>             |          |         heparin is ordered |
|     | </tr>                 |          |         to be              |
|     | <tr class="odd">      |          |         administered.**    |
|     | <td>4. Clopidogrel    |          |                            |
|     | (Plavix)</td>         |          | -   **Low molecular weight |
|     | <td><str              |          |     heparin = may be       |
|     | ong>1,2</strong></td> |          |     prescribed as mg or    |
|     | <td></td>             |          |     units.** For example,  |
|     | <td></td>             |          |     enoxaprin 30 mg subQ   |
|     | </tr>                 |          |     bid. Enter 30 for the  |
|     | <tr class="even">     |          |     dose.                  |
|     | <td>5. Ticlopidine    |          |                            |
|     | (Ticlid)</td>         |          |     -   **Enter the number |
|     | <td><str              |          |         of times a day the |
|     | ong>1,2</strong></td> |          |         low molecular      |
|     | <td></td>             |          |         weight heparin is  |
|     | <td></td>             |          |         ordered to be      |
|     | </tr>                 |          |         administered.**    |
|     | <tr class="odd">      |          |                            |
|     | <td>6. Low dose       |          | **The best source of a     |
|     | unfractionated        |          | patient's discharge        |
|     | heparin               |          | medications is the         |
|     | (<strong>subQ         |          | pharmacy discharge         |
|     | only</strong>)</td>   |          | medication list.**         |
|     | <td><p><st            |          |                            |
|     | rong>1,2</strong></p> |          | **If documentation is      |
|     | <p><strong>If 2,      |          | conflicting, the following |
|     | auto-fill dcunhep     |          | apply:**                   |
|     | as zzzz, and          |          |                            |
|     | dchepfre as           |          | -   In cases where a       |
|     | 95</strong></p></td>  |          |     medication in one      |
|     | <td><p><strong>_ _    |          |     source that is not     |
|     | _ _</strong></p>      |          |     mentioned in other     |
|     | <table>               |          |     sources, it should be  |
|     | <colgroup>            |          |     interpreted as a       |
|     | <col                  |          |     discharge medication   |
|     | s                     |          |     unless documentation   |
|     | tyle="width: 100%" /> |          |     elsewhere in the       |
|     | </colgroup>           |          |     record suggests that   |
|     | <tbody>               |          |     it was not prescribed  |
|     | <tr class="odd">      |          |     at discharge.          |
|     | <td>&gt; 0 and &lt;   |          |     **Consider it a        |
|     | 9999</td>             |          |     discharge medication   |
|     | </tr>                 |          |     in the absence of      |
|     | </tbody>              |          |     contradictory          |
|     | </table></td>         |          |     documentation.**       |
|     | <td></td>             |          |                            |
|     | </tr>                 |          | -   If documentation is    |
|     | <tr class="even">     |          |     contradictory and      |
|     | <td>7. Intravenous    |          |     raises enough          |
|     | (IV) heparin</td>     |          |     questions, the         |
|     | <td><str              |          |     question should be     |
|     | ong>1,2</strong></td> |          |     answered "2."          |
|     | <td></td>             |          |                            |
|     | <td></td>             |          | If a medication is listed  |
|     | </tr>                 |          | as a discharge medication, |
|     | <tr class="odd">      |          | select "1" unless          |
|     | <td>8. Low            |          | contradictory              |
|     | molecular weight      |          | documentation exists. If a |
|     | heparin</td>          |          | medication is not listed   |
|     | <td><p><st            |          | and there is only          |
|     | rong>1,2</strong></p> |          | documentation of a plan to |
|     | <p><strong>If 2,      |          | delay                      |
|     | auto-fill dclmhdos    |          | initiation/restarting of   |
|     | as zzzz, and          |          | the medication for a time  |
|     | dclmhfre</strong></p> |          | period after discharge,    |
|     | <p><strong>as         |          | select "2."                |
|     | 95</strong></p></td>  |          |                            |
|     | <td><p><strong>_ _    |          |                            |
|     | _ _</strong></p>      |          |                            |
|     | <table>               |          |                            |
|     | <colgroup>            |          |                            |
|     | <col                  |          |                            |
|     | s                     |          |                            |
|     | tyle="width: 100%" /> |          |                            |
|     | </colgroup>           |          |                            |
|     | <tbody>               |          |                            |
|     | <tr class="odd">      |          |                            |
|     | <td>&gt; 0 and &lt;   |          |                            |
|     | 9999</td>             |          |                            |
|     | </tr>                 |          |                            |
|     | </tbody>              |          |                            |
|     | </table></td>         |          |                            |
|     | <td></td>             |          |                            |
|     | </tr>                 |          |                            |
|     | <tr class="even">     |          |                            |
|     | <td>9. Alternative    |          |                            |
|     | anticoagulants</td>   |          |                            |
|     | <td><str              |          |                            |
|     | ong>1,2</strong></td> |          |                            |
|     | <td></td>             |          |                            |
|     | <td></td>             |          |                            |
|     | </tr>                 |          |                            |
|     | <tr class="odd">      |          |                            |
|     | <td></td>             |          |                            |
|     | <td                   |          |                            |
|     | cols                  |          |                            |
|     | pan="3"><p><strong>If |          |                            |
|     | dcthrom3 = 2 and      |          |                            |
|     | [pasthx37 = -1 OR     |          |                            |
|     | ipafib] = 1,          |          |                            |
|     | auto-fill dcinrfu     |          |                            |
|     | as 95</strong></p>    |          |                            |
|     | <p><strong>If         |          |                            |
|     | dcthrom3, dcthrom7,   |          |                            |
|     | dcthrom8, or          |          |                            |
|     | dcthrom9 = 1,         |          |                            |
|     | auto-fill whynowar    |          |                            |
|     | as 95</strong></p>    |          |                            |
|     | <p><strong>If         |          |                            |
|     | dcthrom1, dcthrom2,   |          |                            |
|     | dcthrom3, dcthrom4,   |          |                            |
|     | dcthrom5, dcthrom7,   |          |                            |
|     | dcthrom8, or          |          |                            |
|     | dcthrom9 = 1,         |          |                            |
|     | auto-fill nodcanti    |          |                            |
|     | as                    |          |                            |
|     | 95</strong></p></td>  |          |                            |
|     | </tr>                 |          |                            |
|     | </tbody>              |          |                            |
|     | </table>              |          |                            |
|     |                       |          |                            |
|     | **Frequency:**        |          |                            |
|     |                       |          |                            |
|     | 1\. Daily             |          |                            |
|     |                       |          |                            |
|     | 2\. Twice a day (bid) |          |                            |
|     |                       |          |                            |
|     | 3\. Three times a day |          |                            |
|     | (tid)                 |          |                            |
|     |                       |          |                            |
|     | 95\. Not applicable   |          |                            |
|     |                       |          |                            |
|     | 99\. None of the      |          |                            |
|     | above or unable to    |          |                            |
|     | determine             |          |                            |
+-----+-----------------------+----------+----------------------------+
| e   | Was the patient       | 1,2,3,4  | Documentation in the       |
| ddy | screened for          |          | record should indicate     |
| spo | dysphagia before      | If 2,    | that an assessment of the  |
|     | being given any oral  | a        | patient's ability to       |
|     | intake including      | uto-fill | swallow was completed by a |
|     | food, fluids, or      | eddysdt  | health care professional   |
|     | medications by mouth  | as       | prior to oral intake of    |
|     | in the ED?            | 99/      | food, fluids, or           |
|     |                       | 99/9999, | medications. The screening |
|     | 1\. Yes, patient      | eddystm  | test should be a           |
|     | screened for          | as       | standardized method of     |
|     | dysphagia and         | 99:99,   | swallowing assessment      |
|     | documented patient    | edystype | accepted by the facility.  |
|     | able to swallow       | as 95,   | The screening test does    |
|     |                       | and go   | not need to be a formal    |
|     | 2\. No, patient was   | to       | evaluation by a speech and |
|     | not screened for      | hctone   | language pathologist.      |
|     | dysphagia             |          |                            |
|     |                       |          |                            |
|     | 3\. Yes, patient      |          |                            |
|     | screened for          |          |                            |
|     | dysphagia and         |          |                            |
|     | documented unable to  |          |                            |
|     | swallow               |          |                            |
|     |                       |          |                            |
|     | 4\. Yes, patient      |          |                            |
|     | screened for          |          |                            |
|     | dysphagia and         |          |                            |
|     | screening result is   |          |                            |
|     | not documented        |          |                            |
+-----+-----------------------+----------+----------------------------+
| i   | Was an                | 1,2      | Do not include an LDL-c    |
| npt | LDL-cholesterol       |          | value, LDL-c qualitative   |
| ldl | (LDL-c) test          | **If 2,  | description, or lipid      |
|     | performed during this | a        | testing if it cannot be    |
|     | hospital stay?        | uto-fill | determined that the        |
|     |                       | ldldate  | testing was actually done  |
|     |                       | as       | during this hospital stay. |
|     |                       | 99/      |                            |
|     |                       | 99/9999, | Do not include lipid       |
|     |                       | inptldlv | testing or qualitative     |
|     |                       | as       | descriptions of lipid test |
|     |                       | zzz.zz,  | results if it can be       |
|     |                       | inptunit | determined that LDL-c      |
|     |                       | as 95,   | measurement was not part   |
|     |                       | and      | of the lipid testing.      |
|     |                       | ldlqual  |                            |
|     |                       | as 95**  |   ------------------       |
|     |                       |          | -------- ----------------- |
|     |                       |          |   **Inclusion**            |
|     |                       |          |              **Exclusion** |
|     |                       |          |                            |
|     |                       |          |   Low d                    |
|     |                       |          | en lipoprotein        VLDL |
|     |                       |          |                            |
|     |                       |          |   Low de                   |
|     |                       |          | nsity lipoprotein    Alpha |
|     |                       |          |                            |
|     |                       |          |            lipoproteinemia |
|     |                       |          |                            |
|     |                       |          |   *                        |
|     |                       |          | *Qualitative               |
|     |                       |          |   D                        |
|     |                       |          | escription**               |
|     |                       |          |                            |
|     |                       |          |   C                        |
|     |                       |          | hol. Low, normal,          |
|     |                       |          |   e                        |
|     |                       |          | levated, ↑                 |
|     |                       |          |                            |
|     |                       |          |   D                        |
|     |                       |          | yslipidemia (presence or   |
|     |                       |          |   a                        |
|     |                       |          | bsence)                    |
|     |                       |          |                            |
|     |                       |          |   D                        |
|     |                       |          | yslipoproteinemia (same)   |
|     |                       |          |                            |
|     |                       |          |   H                        |
|     |                       |          | yperbetalipoproteinemia    |
|     |                       |          |   (                        |
|     |                       |          | same)                      |
|     |                       |          |                            |
|     |                       |          |   H                        |
|     |                       |          | ypercholesterolemia        |
|     |                       |          |   (                        |
|     |                       |          | same)                      |
|     |                       |          |                            |
|     |                       |          |   H                        |
|     |                       |          | yperlipemia                |
|     |                       |          |                            |
|     |                       |          |   H                        |
|     |                       |          | yperlipidemia              |
|     |                       |          |                            |
|     |                       |          |   H                        |
|     |                       |          | yperlipoproteinemia        |
|     |                       |          |                            |
|     |                       |          |   L                        |
|     |                       |          | DL low, normal, elevated,  |
|     |                       |          |   ↑                        |
|     |                       |          |                            |
|     |                       |          |                            |
|     |                       |          |   L                        |
|     |                       |          | DL above goal, below       |
|     |                       |          |   T                        |
|     |                       |          | arget                      |
|     |                       |          |   ------------------       |
|     |                       |          | -------- ----------------- |
+-----+-----------------------+----------+----------------------------+
| in  | Enter the value of    | \_\_     | If unable to determine     |
| ptl | the first             | \_\_     | which LDL-c test was       |
| dlv | LDL-cholesterol       | \_\_.    | performed first, enter the |
|     | (LDL-c) performed     | \_\_     | highest value.             |
|     | after hospital        | \_\_     |                            |
|     | arrival.              |          | Direct and calculated      |
|     |                       | Will be  | LDL-c values are           |
|     |                       | aut      | acceptable. If both direct |
|     |                       | o-filled | and calculated LDL-c       |
|     |                       | as       | values are documented for  |
|     |                       | zzz.zz   | the same specimen          |
|     |                       | if       | date/time, enter the       |
|     |                       | inptldl  | direct LDL-c value.        |
|     |                       | = 2      |                            |
|     |                       |          | If the LDL-c value on the  |
|     |                       | **If     | laboratory report          |
|     |                       | test was | conflicts with that from   |
|     |                       | done but | another source of          |
|     |                       | LDL-c    | documentation for the same |
|     |                       | value is | specimen, use the value    |
|     |                       | not      | from the laboratory        |
|     |                       | known,   | report.                    |
|     |                       | or if**  |                            |
|     |                       |          | **If progress notes or     |
|     |                       | **high   | order indicate an LDL-c    |
|     |                       | trigl    | level was obtained, but    |
|     |                       | ycerides | the value cannot be found  |
|     |                       | render   | or if high triglycerides   |
|     |                       | LDL-c    | render the LCL-c           |
|     |                       | cal      | calculation inaccurate,    |
|     |                       | culation | enter zzz.zz as the        |
|     |                       | ina      | default value.**           |
|     |                       | ccurate, |                            |
|     |                       | ab       |                            |
|     |                       | stractor |                            |
|     |                       | can      |                            |
|     |                       | enter    |                            |
|     |                       | zzz.zz** |                            |
|     |                       |          |                            |
|     |                       | **If     |                            |
|     |                       | inptldl  |                            |
|     |                       | = 1 but  |                            |
|     |                       | inptldlv |                            |
|     |                       | = zzz,   |                            |
|     |                       | a        |                            |
|     |                       | uto-fill |                            |
|     |                       | inptunit |                            |
|     |                       | as 95**  |                            |
+-----+-----------------------+----------+----------------------------+
| in  | Enter the LDL-C unit  | 1,2,95   | This data must be taken    |
| ptu | of measurement:       |          | from the lab report in     |
| nit |                       | Will be  | order to ensure the        |
|     | 1\. mg/dL             | aut      | correct unit of            |
|     |                       | o-filled | measurement is linked to   |
|     | 2\. mmol/L            | as 95 if | the LDL-C value.           |
|     |                       | inptldl  |                            |
|     | 95\. not applicable   | = 2 or   |                            |
|     |                       | inptldlv |                            |
|     |                       | = zzz.zz |                            |
|     |                       |          |                            |
|     |                       | **If     |                            |
|     |                       | valid    |                            |
|     |                       | value    |                            |
|     |                       | entered  |                            |
|     |                       | in       |                            |
|     |                       | inptldlv |                            |
|     |                       | and      |                            |
|     |                       | inptunit |                            |
|     |                       | = 1 or   |                            |
|     |                       | 2,       |                            |
|     |                       | a        |                            |
|     |                       | uto-fill |                            |
|     |                       | ldlqual  |                            |
|     |                       | as 95,   |                            |
|     |                       | and go   |                            |
|     |                       | to       |                            |
|     |                       | ad       |                            |
|     |                       | mcxray** |                            |
+-----+-----------------------+----------+----------------------------+
| ipa | Does the record       | 1,2      | **Include:** persistent    |
| fib | document that atrial  |          | atrial fibrillation,       |
|     | fibrillation or       | **       | paroxysmal atrial          |
|     | paroxysmal atrial     | Computer | fibrillation, intermittent |
|     | fibrillation was      | to       | atrial fibrillation, PAF,  |
|     | present during the    | a        | discharge ICD-9-CM codes   |
|     | hospital stay?        | uto-fill | 427.31 or 427.32           |
|     |                       | as 1 if  |                            |
|     | 1\. Yes               | strothdx | Suggested data sources:    |
|     |                       | = 427.31 | ECG report with physician  |
|     | 2\. No                | or       | signature, history and     |
|     |                       | 427.32** | physical, progress notes,  |
|     |                       |          | holter monitor report      |
+-----+-----------------------+----------+----------------------------+
| ipn | Did the record        | 1,       | **A clinician must         |
| ons | document any of the   | 2,3,4,99 | document the diagnosis     |
| tr1 | following non-stroke  |          | during the hospital stay.  |
|     | conditions occurred   | 99       | The abstractor may not     |
| ipn | [during]{.underline}  | cannot   | assign a diagnosis based   |
| ons | the hospital stay?    | be       | on past history or         |
| tr2 |                       | entered  | information in the record. |
|     | **Indicate each       | with any | Diagnosis codes must be    |
| ipn | condition and the     | other    | validated by clinician     |
| ons | date of first onset   | number   | documentation.**           |
| tr3 | of the condition      |          |                            |
|     | during the hospital   | mm       |                            |
| ipn | stay:**               | /dd/yyyy |                            |
| ons |                       |          |                            |
| tr4 |   -----               |   --     |                            |
|     | ---------- ---------- | -------- |                            |
| i   |   **C                 |          |                            |
| pno | ondition**   **Date** | \> admdt |                            |
| nst |                       |          |                            |
| r99 |   Inpatient AMI       | and \< = |                            |
|     |                       |          |                            |
| ip  |   Deep Vein           | leftdate |                            |
| non |   Thrombosis          |          |                            |
| 1dt |   (DVT)               |   --     |                            |
|     |                       | -------- |                            |
| ip  |   Pulmonary           |          |                            |
| non |   Embolism (PE)       |          |                            |
| 2dt |                       |          |                            |
|     |   Pneumonia           |          |                            |
| ip  |                       |          |                            |
| non |   None of the         |          |                            |
| 3dt |   above               |          |                            |
|     |   -----               |          |                            |
| ip  | ---------- ---------- |          |                            |
| non |                       |          |                            |
| 4dt |                       |          |                            |
+-----+-----------------------+----------+----------------------------+
| ld  | How was the LDL value | 1,2,3,95 | LDL cholesterol is most    |
| lca | measured?             |          | commonly estimated from    |
| lc1 |                       | If       | quantitative measurements  |
|     | 1.  direct            | ldldone  | of total and               |
|     |                       | = 2,     | HDL-cholesterol and plasma |
|     | ```{=html}            | will be  | triglycerides (TG) using   |
|     | <!-- -->              | aut      | the empirical relationship |
|     | ```                   | o-filled | of Friedewald et al        |
|     | 1.  calculated        | as 95    |                            |
|     |                       |          | **If lab report does not   |
|     | 2.  triglycerides too | **If 3,  | indicate direct or         |
|     |     high to obtain    | z-fill   | calculated, ask the        |
|     |     valid LDL-C       | ldlclvl  | Liaison to determine from  |
|     |                       | and      | the laboratory how LDL     |
|     | ```{=html}            | a        | cholesterol measurement is |
|     | <!-- -->              | uto-fill | obtained in this           |
|     | ```                   | ldlunit  | particular facility.**     |
|     | 95. not applicable    | as 95**  |                            |
+-----+-----------------------+----------+----------------------------+
| l   | Enter the date of the | mm       | Most recent LDL may be     |
| dlc | most recent LDL       | /dd/yyyy | taken from an outpatient   |
| dt1 | measured prior to the |          | or inpatient record within |
|     | admission for acute   |          | one year prior to the      |
|     | ischemic stroke.      |  ------- | index admission for acute  |
|     |                       |   \< = 1 | stroke.                    |
|     |                       |   year   |                            |
|     |                       |   prior  |                            |
|     |                       |   to and |                            |
|     |                       |   \<     |                            |
|     |                       |   admdt  |                            |
|     |                       |          |                            |
|     |                       |          |                            |
|     |                       |  ------- |                            |
+-----+-----------------------+----------+----------------------------+
| l   | Enter the LDL value.  | \_\_     | Normal range is usually 60 |
| dlc |                       | \_\_     | -- 130 mg/dl or less than  |
| lvl |                       | \_\_.    | 3.36 mmol/L (although this |
|     |                       | \_\_     | varies depending on the    |
|     |                       | \_\_\    | way the LDL is calculated, |
|     |                       | If       | if it is not a direct      |
|     |                       | ldldone1 | measurement.)              |
|     |                       | = 2 or   |                            |
|     |                       | ldlcalc1 | Computer will z-fill if    |
|     |                       | = 3,     | LDLDONE1 = 2. Abstractor   |
|     |                       | will be  | cannot z-fill if LDLDONE1  |
|     |                       | z-filled | = 1.                       |
|     |                       |          |                            |
|     |                       | <table>  |                            |
|     |                       | <c       |                            |
|     |                       | olgroup> |                            |
|     |                       | <col     |                            |
|     |                       | style=   |                            |
|     |                       | "width:  |                            |
|     |                       | 100%" /> |                            |
|     |                       | </c      |                            |
|     |                       | olgroup> |                            |
|     |                       | <tbody>  |                            |
|     |                       | <tr      |                            |
|     |                       | clas     |                            |
|     |                       | s="odd"> |                            |
|     |                       | <        |                            |
|     |                       | td><p>Ab |                            |
|     |                       | stractor |                            |
|     |                       | e        |                            |
|     |                       | ntry</p> |                            |
|     |                       | <p>Hard  |                            |
|     |                       | edit:    |                            |
|     |                       | Must     |                            |
|     |                       | be       |                            |
|     |                       | &gt;     |                            |
|     |                       | 0<       |                            |
|     |                       | /p></td> |                            |
|     |                       | </tr>    |                            |
|     |                       | </tbody> |                            |
|     |                       | </table> |                            |
+-----+-----------------------+----------+----------------------------+
| ld  | Enter the LDL-C unit  | 1,2,95   | This data must be taken    |
| lun | of measurement:       |          | from the lab report in     |
| it1 |                       | If       | order to ensure the        |
|     | 1.  mg/dL             | ldldone1 | correct unit of            |
|     |                       | = 2 or   | measurement is linked to   |
|     | ```{=html}            | ldlcalc1 | the LDL-C value.           |
|     | <!-- -->              | = 3,     |                            |
|     | ```                   | will be  | The computer will          |
|     | 1.  mmol/L            | aut      | auto-fill 95 if LDLCLVL is |
|     |                       | o-filled | z-filled. The abstractor   |
|     |     95. not           | as 95    | cannot enter 95 if there   |
|     |         applicable    |          | is a value in LDLCLVL.     |
|     |                       |   ---    |                            |
|     |                       | -------- |                            |
|     |                       |   Ha     |                            |
|     |                       | rd edit: |                            |
|     |                       |   \>     |                            |
|     |                       | 0 and \< |                            |
|     |                       |   4      |                            |
|     |                       | 00 mg/dL |                            |
|     |                       |          |                            |
|     |                       |  or 22.2 |                            |
|     |                       |   m      |                            |
|     |                       | mol/L if |                            |
|     |                       |   ld     |                            |
|     |                       | lcalc1 = |                            |
|     |                       |   2;     |                            |
|     |                       |   oth    |                            |
|     |                       | erwise a |                            |
|     |                       |          |                            |
|     |                       |  warning |                            |
|     |                       |          |                            |
|     |                       |   ---    |                            |
|     |                       | -------- |                            |
+-----+-----------------------+----------+----------------------------+
| le  | # Discharge date:     | mm       | **Auto-filled; cannot be   |
| ftd |                       | /dd/yyyy | modified**                 |
| ate |                       |          |                            |
|     |                       | Auto     |                            |
|     |                       | -filled; |                            |
|     |                       | cannot   |                            |
|     |                       | be       |                            |
|     |                       | modified |                            |
|     |                       |          |                            |
|     |                       |          |                            |
|     |                       |  ------- |                            |
|     |                       |   \>=    |                            |
|     |                       |   admdt  |                            |
|     |                       |          |                            |
|     |                       |          |                            |
|     |                       |  ------- |                            |
+-----+-----------------------+----------+----------------------------+
| l   | # Time of discharge:  | \_\_\    | **Enter time in Universal  |
| eft |                       | _\_\_\_\ | Military** **Time**: a     |
| ime |                       | UMT      | 24-hour period from        |
|     |                       |          | midnight to midnight using |
|     |                       |   -----  | a 4-digit number of which  |
|     |                       | -------- | the first two digits       |
|     |                       |   \>     | indicate the hour and the  |
|     |                       |   adm    | last two digits indicate   |
|     |                       | dt/admtm | the minute.                |
|     |                       |          |                            |
|     |                       |   -----  |                            |
|     |                       | -------- |                            |
+-----+-----------------------+----------+----------------------------+
| li  | Was a lipid-lowering  | 1,2      | Enter "2" if unable to     |
| pda | medication prescribed |          | determine whether a        |
| tdc | at discharge?         | **If 2,  | lipid-lowering medication  |
|     |                       | a        | was prescribed at          |
|     |                       | uto-fill | discharge. If              |
|     |                       | wichlipd | documentation is           |
|     |                       | as 95,   | conflicting, the following |
|     |                       | and go   | apply:                     |
|     |                       | to       |                            |
|     |                       | no       | -   In cases where there   |
|     |                       | lipwhy** |     is a lipid-lowering    |
|     |                       |          |     medication in one      |
|     |                       | **If 1,  |     source that is not     |
|     |                       | a        |     mentioned in another   |
|     |                       | uto-fill |     source, it should be   |
|     |                       | nolipwhy |     interpreted as a       |
|     |                       | as 95**  |     discharge medication   |
|     |                       |          |     unless documentation   |
|     |                       |          |     suggests that it was   |
|     |                       |          |     NOT prescribed at      |
|     |                       |          |     discharge. **Consider  |
|     |                       |          |     it a discharge         |
|     |                       |          |     medication in the      |
|     |                       |          |     absence of             |
|     |                       |          |     contradictory          |
|     |                       |          |     documentation**.       |
|     |                       |          |                            |
|     |                       |          | -   If conflicting         |
|     |                       |          |     documentation raises   |
|     |                       |          |     enough questions after |
|     |                       |          |     careful examination of |
|     |                       |          |     circumstances, the     |
|     |                       |          |     case should be deemed  |
|     |                       |          |     unable to determine    |
|     |                       |          |     and answered as "2."   |
|     |                       |          |                            |
|     |                       |          | ```{=html}                 |
|     |                       |          | <!-- -->                   |
|     |                       |          | ```                        |
|     |                       |          | -   If a lipid-lowering    |
|     |                       |          |     medication is listed   |
|     |                       |          |     as a discharge         |
|     |                       |          |     medication, select "1" |
|     |                       |          |     unless contradictory   |
|     |                       |          |     documentation exists.  |
|     |                       |          |     If a lipid-lowering    |
|     |                       |          |     medication is not      |
|     |                       |          |     listed and there is    |
|     |                       |          |     only documentation of  |
|     |                       |          |     a plan to delay        |
|     |                       |          |     initiation/restarting  |
|     |                       |          |     of a lipid-lowering    |
|     |                       |          |     medication for a time  |
|     |                       |          |     period after           |
|     |                       |          |     discharge, select "2." |
|     |                       |          |                            |
|     |                       |          | **[Lipid-lowering          |
|     |                       |          | Medications]{.underline}** |
|     |                       |          |                            |
|     |                       |          | **HMG-CoA Reductase        |
|     |                       |          | Inhibitors (Statins):**    |
|     |                       |          | fluvastatin sodium         |
|     |                       |          | (Lescol), atorvastatin     |
|     |                       |          | calcium (Lipitor),         |
|     |                       |          | lovastatin (Mevacor)       |
|     |                       |          | (Altocor), pravastatin     |
|     |                       |          | sodium (Pravacol),         |
|     |                       |          | simvastatin (Zocor),       |
|     |                       |          | rosuvastatin calcium       |
|     |                       |          | (Crestor)                  |
|     |                       |          |                            |
|     |                       |          | **Cholesterol absorption   |
|     |                       |          | inhibitors**: ezetimibe    |
|     |                       |          | (Zetia)                    |
|     |                       |          |                            |
|     |                       |          | **Combination**:           |
|     |                       |          | ezetimibe/simvastatin      |
|     |                       |          | (Vytorin),                 |
|     |                       |          | Niaspan/lovastatin         |
|     |                       |          | (Advicor)                  |
|     |                       |          |                            |
|     |                       |          | **Nicotinic Acid:** niacin |
|     |                       |          | extended release tablets   |
|     |                       |          | (Niaspan), Crystalline     |
|     |                       |          | niacin, sustained or timed |
|     |                       |          | release niacin             |
|     |                       |          |                            |
|     |                       |          | **Bile Acid                |
|     |                       |          | Seq                        |
|     |                       |          | uestrants**[:]{.underline} |
|     |                       |          | colestipol hydrochloride   |
|     |                       |          | (Colestid), colesevelam    |
|     |                       |          | hydrochloride (Welchol),   |
|     |                       |          | cholestyramine (Questran)  |
|     |                       |          | (Locholest)                |
|     |                       |          |                            |
|     |                       |          | **Fibrates**: clofibrate   |
|     |                       |          | (Atromid-S) (Abitrate),    |
|     |                       |          | gemfibrozil (Lopid)        |
|     |                       |          | (Gemcor), fenofibrate      |
|     |                       |          | (Tricor) (Lofibra)         |
|     |                       |          |                            |
|     |                       |          | **Omega- Fatty Acids (Fish |
|     |                       |          | Oils):** Marine-derived    |
|     |                       |          | omega-3 fatty acid         |
|     |                       |          | supplements (DHA/EPA)      |
+-----+-----------------------+----------+----------------------------+
| n   | #####                 | mm       | Enter the exact date. The  |
| ihs | # Enter the date the  | /dd/yyyy | use of 01 to indicate      |
| sdt | baseline (first) NIH  |          | missing month or day is    |
|     | Stroke Scale was docu | Will be  | not acceptable.            |
|     | mented in the record. | aut      |                            |
|     |                       | o-filled |                            |
|     |                       | as       |                            |
|     |                       | 99       |                            |
|     |                       | /99/9999 |                            |
|     |                       | if       |                            |
|     |                       |          |                            |
|     |                       | a        |                            |
|     |                       | ssesev99 |                            |
|     |                       | = -1     |                            |
|     |                       |          |                            |
|     |                       |   --     |                            |
|     |                       | -------- |                            |
|     |                       |   \>=    |                            |
|     |                       |          |                            |
|     |                       | arrvdate |                            |
|     |                       |   and \< |                            |
|     |                       |          |                            |
|     |                       | leftdate |                            |
|     |                       |          |                            |
|     |                       |   --     |                            |
|     |                       | -------- |                            |
+-----+-----------------------+----------+----------------------------+
| noa | Does the medical      | 1,2,     | Only select "97", if there |
| mb2 | record document a     | 95,97,99 | is clinician documentation |
|     | reason the patient    |          | linking the reason to the  |
|     | was not ambulatory by | Will be  | non-ambulation of the      |
|     | the end of day two?   | aut      | patient.                   |
|     |                       | o-filled |                            |
|     | 1\. Patient intubated | as 95 if | Suggested Sources:         |
|     |                       | ptamb2 = | Progress notes, rehab      |
|     | 2\. Patient comatose  | 1        | notes, nurse's notes,      |
|     |                       |          | daily ADL/flow sheets      |
|     | 95\. Not applicable   |          |                            |
|     |                       |          |                            |
|     | 97\. Other reason     |          |                            |
|     | documented by         |          |                            |
|     | clinician             |          |                            |
|     |                       |          |                            |
|     | 99\. None of the      |          |                            |
|     | above or unable to    |          |                            |
|     | determine             |          |                            |
+-----+-----------------------+----------+----------------------------+
| no  | Did the               | 1,2,     | **Documentation of a       |
| dca | physician/APN/PA      | 95,98,99 | reason by a                |
| nti | document a reason for |          | physician/APN/PA for not   |
|     | not prescribing       | Will be  | prescribing antithrombotic |
|     | antithrombotic        | aut      | therapy at discharge must  |
|     | therapy at discharge? | o-filled | explicitly link the noted  |
|     |                       | as 95 if | reason with the            |
|     | (Aspirin,             | any      | non-prescription of        |
|     | ASA/dipyridamole,     | dcthrom  | antithrombotic therapy. If |
|     | Aggrenox, warfarin,   | (except  | reasons are not mentioned  |
|     | clopidogrel, Plavix,  | d        | in the context of          |
|     | ticlopidine, Ticlid,  | cthrom6) | antithrombotics, do not    |
|     | heparin, low          | = 1      | make inferences.**         |
|     | molecular weight      |          |                            |
|     | heparin, or           |          | **Examples of reasons for  |
|     | alternative           |          | not prescribing            |
|     | anticoagulants)       |          | antithrombotic therapy     |
|     |                       |          | include but are not        |
|     | 1\. Yes               |          | limited to:**              |
|     |                       |          |                            |
|     | 2\. No                |          | -   Allergy to             |
|     |                       |          |     antithrombotic therapy |
|     | 95\. Not applicable   |          |                            |
|     |                       |          | -   Aortic dissection,     |
|     | 98\. Patient refused  |          |     current                |
|     | antithrombotic        |          |                            |
|     | medications           |          | -   Bleeding disorder      |
|     |                       |          |                            |
|     | 99\. Unable to        |          | -   Brain/CNS cancer       |
|     | determine             |          |                            |
|     |                       |          | -   CVA/hemorrhage         |
|     |                       |          |                            |
|     |                       |          | -   Extensive/metastatic   |
|     |                       |          |     cancer                 |
|     |                       |          |                            |
|     |                       |          | -   Hemorrhage, any type   |
|     |                       |          |                            |
|     |                       |          | -   Intracranial           |
|     |                       |          |     surgery/biopsy         |
|     |                       |          |                            |
|     |                       |          | -   Peptic ulcer, current  |
|     |                       |          |                            |
|     |                       |          | -   Planned surgery within |
|     |                       |          |     7 days of discharge    |
|     |                       |          |                            |
|     |                       |          | -   Risk or bleeding,      |
|     |                       |          |     current                |
|     |                       |          |                            |
|     |                       |          | -   Unrepaired             |
|     |                       |          |     intracranial aneurysm  |
+-----+-----------------------+----------+----------------------------+
| no  | Does the record       | 1,       | Lipid-lowering medication  |
| lip | document any of the   | 97,95,99 | allergy = Where there is   |
| why | following             |          | documentation of a         |
|     | cont                  | Will be  | lipid-lowering medication  |
|     | raindications/reasons | aut      | "allergy" or               |
|     | for not prescribing a | o-filled | "sensitivity", regard this |
|     | lipid-lowering        | as 95 if | as documentation of a      |
|     | medication at         | lipatdc  | lipid-lowering medication  |
|     | discharge?            | = 1      | allergy regardless of what |
|     |                       |          | type of reaction might be  |
|     | 1\. Lipid-lowering    |          | noted. Documentation of an |
|     | medication allergy    |          | allergy/sensitivity to one |
|     |                       |          | particular lipid-lowering  |
|     | 97\. Other reason     |          | medication is acceptable   |
|     | documented by a       |          | to take as an allergy to   |
|     | physician/APN/PA for  |          | the entire class of        |
|     | not prescribing a     |          | lipid-lowering medications |
|     | lipid-lowering        |          | (e.g., "allergic to        |
|     | medication at         |          | atorvastatin").            |
|     | discharge             |          |                            |
|     |                       |          | Reasons for not            |
|     | 95. Not applicable    |          | prescribing a              |
|     |                       |          | lipid-lowering medication  |
|     | 99\. No documented    |          | at discharge must be       |
|     | co                    |          | explicitly documented      |
|     | ntraindication/reason |          | (e.g., "Active PUD. Lipid  |
|     |                       |          | lowering therapy           |
|     |                       |          | contraindicated.") or      |
|     |                       |          | clearly implied (e.g., "Hx |
|     |                       |          | of muscle soreness to      |
|     |                       |          | statins in the past.")     |
|     |                       |          |                            |
|     |                       |          | If reasons are not         |
|     |                       |          | mentioned in the context   |
|     |                       |          | of lipid-lowering          |
|     |                       |          | medications, do not make   |
|     |                       |          | inferences (e.g., do not   |
|     |                       |          | assume that a              |
|     |                       |          | lipid-lowering medication  |
|     |                       |          | is not prescribed because  |
|     |                       |          | of the patient's history   |
|     |                       |          | of alcoholism or severe    |
|     |                       |          | liver disease.)            |
|     |                       |          |                            |
|     |                       |          | Physician/APN/PA           |
|     |                       |          | documentation of a hold on |
|     |                       |          | lipid-lowering medication  |
|     |                       |          | or discontinuation of a    |
|     |                       |          | lipid-lowering medication  |
|     |                       |          | during hospitalization     |
|     |                       |          | constitutes a "clearly     |
|     |                       |          | implied" reason for not    |
|     |                       |          | prescribing a              |
|     |                       |          | lipid-lowering medication  |
|     |                       |          | at discharge. EXCEPTIONS:  |
|     |                       |          |                            |
|     |                       |          | \(1\) Discontinuation of a |
|     |                       |          | particular lipid-lowering  |
|     |                       |          | medication in combination  |
|     |                       |          | with documentation to      |
|     |                       |          | start a different          |
|     |                       |          | lipid-lowering medication; |
|     |                       |          | (2) Lipid-lowering         |
|     |                       |          | medication                 |
|     |                       |          | holds/discontinuations     |
|     |                       |          | which are clearly part of  |
|     |                       |          | set or orders/protocols    |
|     |                       |          | identified as              |
|     |                       |          | preop/pre-procedure; (3)   |
|     |                       |          | Discontinuation of a       |
|     |                       |          | lipid-lowering medication  |
|     |                       |          | at a particular dosage in  |
|     |                       |          | combination with           |
|     |                       |          | documentation to start a   |
|     |                       |          | different dosage of that   |
|     |                       |          | same lipid-lowering        |
|     |                       |          | medication; (4)            |
|     |                       |          | Physician/APN/PA order for |
|     |                       |          | a one-time hold; (5)       |
|     |                       |          | Physician/APN/PA           |
|     |                       |          | documentation of a         |
|     |                       |          | conditional hold or        |
|     |                       |          | discontinuation of a       |
|     |                       |          | lipid-lowering medication  |
|     |                       |          | (e.g., "hold Zocor if      |
|     |                       |          | diarrhea persists.")       |
|     |                       |          |                            |
|     |                       |          | Reasons do not need to be  |
|     |                       |          | documented at the time of  |
|     |                       |          | discharge or otherwise     |
|     |                       |          | associated specifically    |
|     |                       |          | with discharge             |
|     |                       |          | prescription.              |
|     |                       |          | Documentation of           |
|     |                       |          | contraindications anytime  |
|     |                       |          | during the stay are        |
|     |                       |          | acceptable.                |
|     |                       |          |                            |
|     |                       |          | Physician/APN/PA           |
|     |                       |          | documentation of a         |
|     |                       |          | pre-arrival hold,          |
|     |                       |          | discontinuation of a       |
|     |                       |          | lipid-lowering medication, |
|     |                       |          | or "other reason" counts   |
|     |                       |          | as a reason for not        |
|     |                       |          | prescribing a              |
|     |                       |          | lipid-lowering medication  |
|     |                       |          | at discharge ONLY if the   |
|     |                       |          | underlying reason is       |
|     |                       |          | noted.                     |
|     |                       |          |                            |
|     |                       |          | Lipid-lowering medications |
|     |                       |          | may also be referred to as |
|     |                       |          | bile acid sequestrants,    |
|     |                       |          | fibric acid derivatives,   |
|     |                       |          | fibrates, HMG CoA          |
|     |                       |          | reductase inhibitors       |
|     |                       |          | (statins), resin drugs,    |
|     |                       |          | and nicotinic acid.        |
+-----+-----------------------+----------+----------------------------+
| no  | By the end of         | 1,2,95   | Venous thromboembolism     |
| mec | hospital day two, was |          | (VTE) is the formation,    |
| pro | there                 | Will be  | development, or existence  |
|     | physician/APN/PA      | aut      | of a blood clot or         |
|     | documentation in the  | o-filled | thrombus within the venous |
|     | medical record of a   | as 95 if | system.                    |
|     | contraindication to   | vtemech  |                            |
|     | mechanical venous     | = 1      | **Mechanical prophylaxis** |
|     | thromboembolism (VTE) |          | = compression devices or   |
|     | prophylaxis?          |          | stockings such as          |
|     |                       |          | anti-embolism hose used to |
|     | 1.  Yes               |          | prevent VTE                |
|     |                       |          |                            |
|     | ```{=html}            |          | **In order to select "1,"  |
|     | <!-- -->              |          | there must be              |
|     | ```                   |          | physician/APN/PA           |
|     | 1.  No                |          | documentation of a         |
|     |                       |          | contraindication to        |
|     | ```{=html}            |          | mechanical VTE             |
|     | <!-- -->              |          | prophylaxis.**             |
|     | ```                   |          |                            |
|     | 95. Not applicable    |          |                            |
+-----+-----------------------+----------+----------------------------+
| non | Did the record        | 1,2,3,4, | **A clinician must         |
| str | document any of the   | 5,6,7,99 | document the diagnosis on  |
| dx1 | following non-stroke  |          | arrival. The intent is to  |
|     | conditions were       |          | determine whether any of   |
| non | [present on           |          | these conditions were      |
| str | arrival]{.underline}? |          | documented as an acute     |
| dx2 |                       |          | problem or as an           |
|     | **Indicate all that   |          | exacerbation of the        |
| non | apply:**              |          | condition upon arrival.**  |
| str |                       |          |                            |
| dx3 | 1\. Aortic Dissection |          | **The abstractor may not   |
|     |                       |          | assign a diagnosis based   |
| non | 2\. Acute Heart       |          | on past medical history.   |
| str | Failure               |          | Do not include conditions  |
| dx4 |                       |          | described as a past        |
|     | 3\. Hypertensive      |          | problem or chronic         |
| non | encephalopathy        |          | problem. Diagnosis codes   |
| str |                       |          | must be validated by       |
| dx5 | 4\. Pneumonia         |          | clinician documentation.** |
|     |                       |          |                            |
| non | 5\. Acute Myocardial  |          | **Aortic dissection =** a  |
| str | Infarction            |          | potentially                |
| dx6 |                       |          | life-threatening condition |
|     | 6\. Acute Renal       |          | in which there is bleeding |
| non | failure               |          | into and along the wall of |
| str |                       |          | the aorta, the major       |
| dx7 | 7\. Major Trauma      |          | artery leaving the heart.  |
|     |                       |          |                            |
| n   | 99\. None of the      |          | **Acute Myocardial         |
| ons | above                 |          | Infarction** would include |
| trd |                       |          | documentation of a STEMI   |
| x99 |                       |          | or NSTEMI on arrival.      |
|     |                       |          |                            |
|     |                       |          | **Acute Heart Failure** =  |
|     |                       |          | only include documentation |
|     |                       |          | of acute heart failure or  |
|     |                       |          | exacerbation of heart      |
|     |                       |          | failure that is present on |
|     |                       |          | arrival                    |
|     |                       |          |                            |
|     |                       |          | **Hypertensive             |
|     |                       |          | encephalopathy** = damage  |
|     |                       |          | to the brain and nervous   |
|     |                       |          | system as a result of a    |
|     |                       |          | severely high blood        |
|     |                       |          | pressure                   |
|     |                       |          |                            |
|     |                       |          | **Major Trauma =** trauma  |
|     |                       |          | that results in an injury  |
|     |                       |          | such as fracture or        |
|     |                       |          | dislocation, loss of       |
|     |                       |          | consciousness, internal    |
|     |                       |          | bleeding, or bleeding      |
|     |                       |          | requiring transfusion      |
+-----+-----------------------+----------+----------------------------+
| nor | Enter the time the    | \_       | If the last time the       |
| mtm | patient was last      | \_\_\_\_ | patient was known to be    |
|     | known to be well.     |          | well is documented as a    |
|     |                       | UMT      | specific number of hours   |
|     |                       |          | prior to arrival (e.g., 2  |
|     |                       | **Ab     | hours ago) rather than a   |
|     |                       | stractor | specific time, subtract    |
|     |                       | can      | that number from the time  |
|     |                       | enter    | of hospital arrival and    |
|     |                       | 99:99**  | enter that time.           |
|     |                       |          |                            |
|     |                       | If \<\>  | If the time is reported as |
|     |                       | 99:99,   | a range of time (e.g., 2   |
|     |                       | a        | -- 3 hours ago), assume    |
|     |                       | uto-fill | the maximum time (3 hours) |
|     |                       | welgentm | and subtract that number   |
|     |                       | as 95    | from the time of hospital  |
|     |                       | and go   | arrival. **If the stroke   |
|     |                       | to       | onset time is documented   |
|     |                       | seizure  | in the medical record      |
|     |                       |          | without reference to       |
|     |                       |          | circumstances preceding    |
|     |                       |          | detection of stroke, infer |
|     |                       |          | this to be when the        |
|     |                       |          | patient was last known to  |
|     |                       |          | be well.**                 |
|     |                       |          |                            |
|     |                       |          | If the time cannot be      |
|     |                       |          | determined, enter 99:99.   |
+-----+-----------------------+----------+----------------------------+
| n   | By the end of         | 1,2      | Venous thromboembolism     |
| orx | hospital day two, was |          | (VTE) is the formation,    |
| pro | there                 |          | development, or existence  |
|     | physician/APN/PA      |          | of a blood clot or         |
|     | documentation in the  |          | thrombus within the venous |
|     | medical record of a   |          | system.                    |
|     | contraindication to   |          |                            |
|     | pharmacological       |          | **Pharmacological          |
|     | venous                |          | prophylaxis** =            |
|     | thromboembolism (VTE) |          | medications used to        |
|     | prophylaxis?          |          | prevent VTE such as        |
|     |                       |          | Heparin, Warfarin          |
|     | **(Warfarin, heparin, |          | (Coumadin), or Lovenox     |
|     | low molecular weight  |          |                            |
|     | heparin, alternative  |          | **In order to select "1,"  |
|     | anticoagulants)**     |          | there must be physician,   |
|     |                       |          | APN, or PA documentation   |
|     | 1.  Yes               |          | of a contraindication to   |
|     |                       |          | pharmacological VTE        |
|     | ```{=html}            |          | prophylaxis**. Categories  |
|     | <!-- -->              |          | of VTE pharmacological     |
|     | ```                   |          | prophylaxis include:       |
|     | 1.  No                |          |                            |
|     |                       |          | -   **Warfarin** such as:  |
|     |                       |          |     Coumadin, Jantoven,    |
|     |                       |          |     Panwarfin, Warfilone   |
|     |                       |          |                            |
|     |                       |          | -   **Low dose             |
|     |                       |          |     unfractionated         |
|     |                       |          |     heparin** (LDUH) --    |
|     |                       |          |     **only include heparin |
|     |                       |          |     administered by        |
|     |                       |          |                            |
|     |                       |          | [subcutaneous]{.underline} |
|     |                       |          |     route** (SC, SQ, SubQ) |
|     |                       |          |     LDUH such as: heparin, |
|     |                       |          |     calcilean, calciparine |
|     |                       |          |                            |
|     |                       |          | -   **Intravenous          |
|     |                       |          |     heparin**              |
|     |                       |          |                            |
|     |                       |          | -   **Low molecular weight |
|     |                       |          |     heparin** (LMWH) such  |
|     |                       |          |     as: enoxaparin         |
|     |                       |          |     (Lovenox), fragmin,    |
|     |                       |          |     innohep                |
|     |                       |          |                            |
|     |                       |          | -   **Alternative          |
|     |                       |          |     anticoagulants** such  |
|     |                       |          |     as danaparoid          |
|     |                       |          |     (Organon), hirudin     |
|     |                       |          |     (Lepirudin),           |
|     |                       |          |     bivalirudin            |
|     |                       |          |     (Angiomax), other      |
|     |                       |          |     heparinoids            |
+-----+-----------------------+----------+----------------------------+
| np  | Did the patient       | 1,\*2    | NPO = nothing by mouth     |
| oed | receive any oral      |          |                            |
|     | intake including      | \*If 2,  | If the patient received    |
|     | food, fluids, or      | go to    | any food, fluids, or       |
|     | medications by mouth  | hctone,  | medications by mouth,      |
|     | in the ED?            | else go  | answer "1."                |
|     |                       | to       |                            |
|     |                       | eddyspo. | If the patient was kept    |
|     |                       |          | NPO the during the entire  |
|     |                       |          | ED stay, answer "2."       |
|     |                       |          |                            |
|     |                       |          | Do not consider the        |
|     |                       |          | delivery of food, fluid,   |
|     |                       |          | or medication via a        |
|     |                       |          | nasogastric tube,          |
|     |                       |          | orogastric tube, or        |
|     |                       |          | percutaneous gastrostomy   |
|     |                       |          | tube as intake by mouth    |
|     |                       |          | (oral intake).             |
+-----+-----------------------+----------+----------------------------+
| pa  | History of atrial     | **In     | **Include:** persistent    |
| sth | fibrillation or       | clude:** | atrial fibrillation,       |
| x37 | paroxysmal atrial     | pe       | paroxysmal atrial          |
|     | fibrillation          | rsistent | fibrillation, intermittent |
|     |                       | atrial   | atrial fibrillation, PAF,  |
|     |                       | fibri    | history of any episode of  |
|     |                       | llation, | documented atrial          |
|     |                       | pa       | fibrillation or flutter    |
|     |                       | roxysmal | lasting greater than 30    |
|     |                       | atrial   | seconds except within 8    |
|     |                       | fibri    | weeks following CABG       |
|     |                       | llation, |                            |
|     |                       | inte     | **Exclude:** Atrial        |
|     |                       | rmittent | fibrillation described as  |
|     |                       | atrial   | remote and/or              |
|     |                       | fibri    | self-limited, a history of |
|     |                       | llation, | self-limited atrial        |
|     |                       | PAF,     | fibrillation or atrial     |
|     |                       | history  | flutter that terminated    |
|     |                       | of any   | within 8 weeks following   |
|     |                       | episode  | CABG.                      |
|     |                       | of       |                            |
|     |                       | do       |                            |
|     |                       | cumented |                            |
|     |                       | atrial   |                            |
|     |                       | fibr     |                            |
|     |                       | illation |                            |
|     |                       | or       |                            |
|     |                       | flutter  |                            |
|     |                       | lasting  |                            |
|     |                       | greater  |                            |
|     |                       | than 30  |                            |
|     |                       | seconds  |                            |
|     |                       | except   |                            |
|     |                       | within 8 |                            |
|     |                       | weeks    |                            |
|     |                       | f        |                            |
|     |                       | ollowing |                            |
|     |                       | CABG     |                            |
|     |                       |          |                            |
|     |                       | **Ex     |                            |
|     |                       | clude:** |                            |
|     |                       | Atrial   |                            |
|     |                       | fibr     |                            |
|     |                       | illation |                            |
|     |                       | d        |                            |
|     |                       | escribed |                            |
|     |                       | as       |                            |
|     |                       | remote   |                            |
|     |                       | and/or   |                            |
|     |                       | self-    |                            |
|     |                       | limited, |                            |
|     |                       | a        |                            |
|     |                       | history  |                            |
|     |                       | of       |                            |
|     |                       | self     |                            |
|     |                       | -limited |                            |
|     |                       | atrial   |                            |
|     |                       | fibr     |                            |
|     |                       | illation |                            |
|     |                       | or       |                            |
|     |                       | atrial   |                            |
|     |                       | flutter  |                            |
|     |                       | that     |                            |
|     |                       | te       |                            |
|     |                       | rminated |                            |
|     |                       | within 8 |                            |
|     |                       | weeks    |                            |
|     |                       | f        |                            |
|     |                       | ollowing |                            |
|     |                       | CABG.    |                            |
+-----+-----------------------+----------+----------------------------+
| pr  | Was the patient       | 1,2,99   | **Ambulatory includes:**   |
| est | ambulatory prior to   |          |                            |
| amb | the stroke?           |          | -   patient ambulating     |
|     |                       |          |     without assistance     |
|     | 1\. Yes               |          |     from another person    |
|     |                       |          |     (with or without use   |
|     | 2\. No                |          |     of assistive device)   |
|     |                       |          |                            |
|     | 99\. Unable to        |          | -   Patient ambulating to  |
|     | determine             |          |     and from the bathroom  |
|     |                       |          |     without assistance     |
|     |                       |          |                            |
|     |                       |          | > **Non-ambulatory         |
|     |                       |          | > includes:**              |
|     |                       |          |                            |
|     |                       |          | -   Patient is on bed rest |
|     |                       |          |                            |
|     |                       |          | -   Patient is only        |
|     |                       |          |     getting out of bed to  |
|     |                       |          |     the bedside commode    |
|     |                       |          |     (or up in chair) or is |
|     |                       |          |     primarily in the bed   |
|     |                       |          |     (or immobile)          |
|     |                       |          |                            |
|     |                       |          | -   Up to bathroom with    |
|     |                       |          |     assistance of another  |
|     |                       |          |     person                 |
|     |                       |          |                            |
|     |                       |          | Suggested data sources: ED |
|     |                       |          | notes, admission notes,    |
|     |                       |          | nursing assessment, H&P,   |
|     |                       |          | progress notes, rehab      |
|     |                       |          | notes                      |
+-----+-----------------------+----------+----------------------------+
| pta | Does the medical      | 1,2,99   | **Day of arrival counts as |
| mb2 | record document the   |          | hospital day 1.**          |
|     | patient was           | If 1,    |                            |
|     | ambulatory by the end | a        | **Ambulatory includes:**   |
|     | of hospital day two?  | uto-fill |                            |
|     |                       | noamb2   | -   patient ambulating     |
|     | 1\. Yes               | as 95,   |     without assistance     |
|     |                       | and go   |     from another person    |
|     | 2\. No                | to       |     (with or without use   |
|     |                       | wi       |     of assistive device)   |
|     | 99\. Unable to        | cthrom1, |                            |
|     | determine             | else go  | -   Patient ambulating to  |
|     |                       | to       |     and from the bathroom  |
|     |                       | noamb2   |     without assistance     |
|     |                       |          |                            |
|     |                       |          | > **Non-ambulatory         |
|     |                       |          | > includes:**              |
|     |                       |          |                            |
|     |                       |          | -   Patient is on bed rest |
|     |                       |          |                            |
|     |                       |          | -   Patient is only        |
|     |                       |          |     getting out of bed to  |
|     |                       |          |     the bedside commode    |
|     |                       |          |     (or up in chair) or is |
|     |                       |          |     primarily in the bed   |
|     |                       |          |     (or immobile)          |
|     |                       |          |                            |
|     |                       |          | -   Up to bathroom with    |
|     |                       |          |     assistance of another  |
|     |                       |          |     person                 |
+-----+-----------------------+----------+----------------------------+
| R   | Review Status         |          |                            |
| evs |                       |          |                            |
| tat | 1.  Abstraction has   |          |                            |
|     |     not begun         |          |                            |
|     |                       |          |                            |
|     | 2.  Abstraction in    |          |                            |
|     |     progress          |          |                            |
|     |                       |          |                            |
|     | 3.  Abstraction       |          |                            |
|     |     completed w/o     |          |                            |
|     |     errors            |          |                            |
|     |                       |          |                            |
|     | 4.  TVG failure       |          |                            |
|     |     (exclusion)       |          |                            |
|     |                       |          |                            |
|     | 5.  Record contains   |          |                            |
|     |     missing required  |          |                            |
|     |     answers (error    |          |                            |
|     |     record)           |          |                            |
+-----+-----------------------+----------+----------------------------+
| sc  | After admission, was  | 1        | Documentation in the       |
| rdy | the patient           | ,2,97,99 | record should indicate     |
| spo | screened/evaluated    |          | that an assessment of the  |
|     | for dysphagia before  | If 2,    | patient's ability to       |
|     | being given any oral  | 97, or   | swallow was completed by a |
|     | intake including      | 99,      | health care professional   |
|     | food, fluids, or      | a        | prior to oral intake of    |
|     | medications by mouth? | uto-fill | food, fluids, or           |
|     |                       | podysdt  | medications. The screening |
|     | 1\. Yes               | as       | test or evaluation should  |
|     |                       | 99       | be a standardized method   |
|     | 2\. No                | /99/9999 | of swallowing assessment   |
|     |                       | podystm  | accepted by the facility.  |
|     | 97\. Reason           | as       | The screening test does    |
|     | documented by         | 99:99,   | not need to be a formal    |
|     | physician/APN/PA for  | typoscrn | evaluation by a speech and |
|     | not performing        | as 95,   | language pathologist.      |
|     | screening/evaluation  | swalout  |                            |
|     | for dysphagia prior   | as 95,   | Reasons for not performing |
|     | to oral intake        | and      | a dysphagia                |
|     |                       | whoscr   | screen/evaluation before   |
|     | 99\. Unable to        | as 95,   | PO intake must be          |
|     | determine             | and go   | explicitly documented or   |
|     |                       | to       | clearly implied by the     |
|     |                       | ktconcom | physician/APN/PA. If the   |
|     |                       |          | reason is not mentioned in |
|     |                       |          | the context of dysphagia   |
|     |                       |          | screening, do not make     |
|     |                       |          | inferences.                |
+-----+-----------------------+----------+----------------------------+
| sm  | Did the adult patient | 1,2      | This question refers only  |
| okc | smoke cigarettes any  |          | to smoking cigarettes and  |
| igs | time during the year  | **If 2,  | is not pertinent to other  |
|     | prior to hospital     | a        | forms of tobacco**. If the |
|     | arrival?              | uto-fill | record documents "tobacco  |
|     |                       | tobcess  | use" or "+smoker" but the  |
|     | 1.  Yes               | as 95**  | type of product is not     |
|     |                       |          | specified, assume this     |
|     | ```{=html}            |          | refers to** **cigarette    |
|     | <!-- -->              |          | smoking.**                 |
|     | ```                   |          |                            |
|     | 1.  No or unable to   |          | If there is documentation  |
|     |     determine from    |          | anywhere in the **ONLY     |
|     |     medical record    |          | ACCEPTABLE SOURCES** that  |
|     |     documentation     |          | the patient either         |
|     |                       |          | currently smokes or is an  |
|     | #####                 |          | ex-smoker that quit less   |
|     |                       |          | than one year prior to     |
|     |                       |          | hospitalization, select    |
|     |                       |          | "yes," **regardless of     |
|     |                       |          | whether or not there is    |
|     |                       |          | conflicting                |
|     |                       |          | documentation.** **In all  |
|     |                       |          | other cases, "no" should   |
|     |                       |          | be selected.**             |
|     |                       |          |                            |
|     |                       |          | If there is documentation  |
|     |                       |          | of a history of smoking    |
|     |                       |          | and that the patient quit  |
|     |                       |          | "several months ago,"      |
|     |                       |          | select "yes."              |
|     |                       |          |                            |
|     |                       |          | Disregard documentation of |
|     |                       |          | smoking history or history |
|     |                       |          | of tobacco use if current  |
|     |                       |          | smoking status or          |
|     |                       |          | timeframe that patient     |
|     |                       |          | quit is not defined (e.g., |
|     |                       |          | "20 pk/yr smoking          |
|     |                       |          | history", "History of      |
|     |                       |          | tobacco abuse").           |
|     |                       |          |                            |
|     |                       |          | Do not include             |
|     |                       |          | documentation of smoking   |
|     |                       |          | history referenced as a    |
|     |                       |          | risk factor (e.g., "risk   |
|     |                       |          | factor: tobacco," "risk    |
|     |                       |          | factor: smoking,"), where  |
|     |                       |          | current smoking status is  |
|     |                       |          | indeterminable.            |
|     |                       |          |                            |
|     |                       |          | **ONLY ACCEPTABLE          |
|     |                       |          | SOURCES:** Emergency       |
|     |                       |          | department record, history |
|     |                       |          | and physical, nursing      |
|     |                       |          | admission/nursing          |
|     |                       |          | admission notes,           |
|     |                       |          | respiratory therapy notes  |
+-----+-----------------------+----------+----------------------------+
| st  | Enter the patient's   | 1,2,     | 1 = Discharged to home     |
| rok | discharge             | 3,4,5,6, | care or self care =        |
| edc | disposition:          | 7,20,43, | includes discharge to      |
|     |                       |          | home; jail or law          |
|     | 1.  discharged to     | 50,51    | enforcement; home on       |
|     |     home care or self | ,61,62,\ | oxygen if DMS only; any    |
|     |     care (routine     | 63,      | other DMS only; group      |
|     |     discharge)        | 64,65,66 | home, foster care, and     |
|     |                       |          | other residential care     |
|     | ```{=html}            |          | arrangements; outpatient   |
|     | <!-- -->              |          | programs, such as partial  |
|     | ```                   |          | hospitalization or         |
|     | 2.  d                 |          | outpatient chemical        |
|     | ischarged/transferred |          | dependency programs;       |
|     |     to a short term   |          | assisted living facilities |
|     |     general hospital  |          | that are not               |
|     |     for inpatient     |          | state-designated;          |
|     |     care              |          | domiciliary.               |
|     |                       |          |                            |
|     | 3.  d                 |          | 5 = Discharged/transferred |
|     | ischarged/transferred |          | to another Type of Health  |
|     |     to a skilled      |          | Care Institution not       |
|     |     nursing facility  |          | Defined Elsewhere in this  |
|     |     (SNF) with        |          | Code List = includes       |
|     |     Medicare          |          | Cancer hospitals excluded  |
|     |     certification,    |          | from Medicare PPS and      |
|     |     **in anticipation |          | children's hospitals.      |
|     |     of covered        |          |                            |
|     |     skilled care**    |          | To respond "2," it must be |
|     |                       |          | known the "other" hospital |
|     | 4.  d                 |          | is an acute-care facility, |
|     | ischarged/transferred |          | and the patient's          |
|     |     to an             |          | anticipated admission is   |
|     |     intermediate care |          | the same day as discharge  |
|     |     facility          |          | from the VAMC.             |
|     |                       |          |                            |
|     | 5.  d                 |          | To respond "7," a signed   |
|     | ischarged/transferred |          | AMA document, or progress  |
|     |     to another type   |          | note by a physician, APN,  |
|     |     of Health Care    |          | or PA must appear in the   |
|     |     Institution not   |          | record.                    |
|     |     Defined Elsewhere |          |                            |
|     |     in this Code List |          | If discharged to TCU       |
|     |                       |          | (Transitional Care Unit)   |
|     | 6.  d                 |          | of a nursing home, use     |
|     | ischarged/transferred |          | option #4. Be certain the  |
|     |     to home **under   |          | designation of TCU does    |
|     |     care of organized |          | not mean a step-down unit  |
|     |     home health       |          | from an intensive care     |
|     |     service           |          | unit.                      |
|     |     organization in   |          |                            |
|     |     anticipation of   |          | Use option #43 for         |
|     |     covered skilled   |          | discharges and transfers   |
|     |     care\             |          | to a government operated   |
|     |     **Report this     |          | health care facility such  |
|     |     code when the     |          | as a Department of Defense |
|     |     patient is        |          | hospital, a Veteran's      |
|     |     d                 |          | Administration hospital or |
|     | ischarged/transferred |          | a Veteran's Administration |
|     |     to home **with a  |          | nursing facility. To be    |
|     |     written plan of   |          | used whenever the          |
|     |     care** (tailored  |          | destination at discharge   |
|     |     to the patient's  |          | is a federal health care   |
|     |     medical needs)    |          | facility, whether the      |
|     |     **for home care   |          | patient resides there or   |
|     |     services.**       |          | not.                       |
|     |                       |          |                            |
|     | 7.  left against      |          | Option #62 is for          |
|     |     medical advice or |          | discharges and transfers   |
|     |     discontinued care |          | to an inpatient            |
|     |                       |          | rehabilitation facility    |
|     | ```{=html}            |          | which includes             |
|     | <!-- -->              |          | rehabilitation distinct    |
|     | ```                   |          | part units of a hospital.  |
|     | 20. expired           |          |                            |
|     |                       |          |                            |
|     | ```{=html}            |          |                            |
|     | <!-- -->              |          |                            |
|     | ```                   |          |                            |
|     | 43. D                 |          |                            |
|     | ischarged/transferred |          |                            |
|     |     to a federal      |          |                            |
|     |     health care       |          |                            |
|     |     facility          |          |                            |
|     |                       |          |                            |
|     | ```{=html}            |          |                            |
|     | <!-- -->              |          |                            |
|     | ```                   |          |                            |
|     | 50. hospice -- home   |          |                            |
|     |                       |          |                            |
|     | ```{=html}            |          |                            |
|     | <!-- -->              |          |                            |
|     | ```                   |          |                            |
|     | 51. hospice --        |          |                            |
|     |     medical facility  |          |                            |
|     |     (certified)       |          |                            |
|     |     providing hospice |          |                            |
|     |     level of care     |          |                            |
|     |                       |          |                            |
|     | ```{=html}            |          |                            |
|     | <!-- -->              |          |                            |
|     | ```                   |          |                            |
|     | 61. d                 |          |                            |
|     | ischarged/transferred |          |                            |
|     |     to hospital-based |          |                            |
|     |     Medicare approved |          |                            |
|     |     swing bed         |          |                            |
|     |                       |          |                            |
|     | 62. D                 |          |                            |
|     | ischarged/transferred |          |                            |
|     |     to inpatient      |          |                            |
|     |     rehabilitation    |          |                            |
|     |     facility (IRF)    |          |                            |
|     |     including         |          |                            |
|     |     rehabilitation    |          |                            |
|     |     distinct parts of |          |                            |
|     |     a hospital        |          |                            |
|     |                       |          |                            |
|     | 63. D                 |          |                            |
|     | ischarged/transferred |          |                            |
|     |     to a Medicare     |          |                            |
|     |     certified         |          |                            |
|     |     long-term care    |          |                            |
|     |     hospital          |          |                            |
|     |                       |          |                            |
|     | 64. D                 |          |                            |
|     | ischarged/transferred |          |                            |
|     |     to a nursing      |          |                            |
|     |     facility          |          |                            |
|     |     certified under   |          |                            |
|     |     Medicaid but not  |          |                            |
|     |     certified under   |          |                            |
|     |     Medicare          |          |                            |
|     |                       |          |                            |
|     | 65. D                 |          |                            |
|     | ischarged/transferred |          |                            |
|     |     to a psychiatric  |          |                            |
|     |     hospital or       |          |                            |
|     |     psychiatric       |          |                            |
|     |     distinct part     |          |                            |
|     |     unit of a         |          |                            |
|     |     hospital          |          |                            |
|     |                       |          |                            |
|     | 66\.                  |          |                            |
|     | D                     |          |                            |
|     | ischarged/transferred |          |                            |
|     | to a Critical Access  |          |                            |
|     | Hospital (CAH)        |          |                            |
+-----+-----------------------+----------+----------------------------+
| st  | # Was acute ischem    | 1,2,\*3  | **Principal diagnosis =    |
| rok | ic stroke the princip |          | that condition established |
| edx | al or secondary diagn | **\*If   | after study to be chiefly  |
|     | osis for the episode  | 3, the   | responsible for            |
|     | of care under review? | case is  | occasioning the admission  |
|     |                       | ex       | of the patient to the      |
|     | 1\. Principal         | cluded** | hospital for care.**       |
|     | diagnosis             |          |                            |
|     |                       |          | **Secondary or other       |
|     | 2\. Secondary         |          | diagnosis = all conditions |
|     | diagnosis             |          | that coexist at the time   |
|     |                       |          | of admission, that develop |
|     | 3\. Stroke listed as  |          | subsequently, or that      |
|     | secondary diagnosis,  |          | affect the treatment       |
|     | but not treated       |          | received or the length of  |
|     | during this episode   |          | stay.**                    |
|     | of care               |          |                            |
|     |                       |          | **Option #3 = ischemic     |
|     |                       |          | stroke diagnosis that is   |
|     |                       |          | related to an earlier      |
|     |                       |          | stroke episode and has no  |
|     |                       |          | bearing on the current     |
|     |                       |          | hospital stay**            |
+-----+-----------------------+----------+----------------------------+
| st  | Enter the date the    | mm       | Enter the exact date the   |
| rsy | patient first         | /dd/yyyy | patient first experienced  |
| mdt | experienced stroke    |          | stroke symptoms. The use   |
|     | symptoms.             | <table>  | of 01 to indicate missing  |
|     |                       | <c       | month or day is not        |
|     |                       | olgroup> | acceptable.                |
|     |                       | <col     |                            |
|     |                       | style=   |                            |
|     |                       | "width:  |                            |
|     |                       | 100%" /> |                            |
|     |                       | </c      |                            |
|     |                       | olgroup> |                            |
|     |                       | <tbody>  |                            |
|     |                       | <tr      |                            |
|     |                       | clas     |                            |
|     |                       | s="odd"> |                            |
|     |                       | <td      |                            |
|     |                       | ><p>&lt; |                            |
|     |                       | = 1      |                            |
|     |                       | month    |                            |
|     |                       | prior    |                            |
|     |                       | to or    |                            |
|     |                       | =        |                            |
|     |                       | arrvdate |                            |
|     |                       | and</p>  |                            |
|     |                       | <p>&lt;  |                            |
|     |                       | =        |                            |
|     |                       | admdt<   |                            |
|     |                       | /p></td> |                            |
|     |                       | </tr>    |                            |
|     |                       | </tbody> |                            |
|     |                       | </table> |                            |
|     |                       |          |                            |
|     |                       | Will be  |                            |
|     |                       | aut      |                            |
|     |                       | o-filled |                            |
|     |                       | as       |                            |
|     |                       | 99       |                            |
|     |                       | /99/9999 |                            |
|     |                       | if       |                            |
|     |                       | st       |                            |
|     |                       | roksym99 |                            |
|     |                       | = -1     |                            |
+-----+-----------------------+----------+----------------------------+
| st  | Enter the time the    | \_       | **If the exact time the    |
| rsy | patient first         | \_\_\_\_ | patient first experienced  |
| mtm | experienced stroke    |          | stroke symptoms is not     |
|     | symptoms.             | UMT      | documented, but can be     |
|     |                       |          | calculated based on        |
|     |                       | Will be  | documentation of events,   |
|     |                       | aut      | the abstractor can         |
|     |                       | o-filled | calculate and enter that   |
|     |                       | as 99:99 | time**. For example, the   |
|     |                       | if       | time of ED arrival is      |
|     |                       | st       | known to be 06:45 and the  |
|     |                       | roksym99 | ED note states, "symptoms  |
|     |                       | = -1     | started 45 minutes prior   |
|     |                       |          | to arrival." Enter 06:00.  |
|     |                       | Ab       |                            |
|     |                       | stractor | **If the decision to give  |
|     |                       | can      | thrombolytics is made and  |
|     |                       | enter    | a more recent time for     |
|     |                       | 99:99    | symptom onset is           |
|     |                       |          | documented, enter the more |
|     |                       | If \<\>  | recent time.**             |
|     |                       | 99:99,   |                            |
|     |                       | a        | **If there are multiple    |
|     |                       | uto-fill | times of symptom onset     |
|     |                       | strgentm | documented at the time the |
|     |                       | as 95,   | treatment decision is      |
|     |                       | and go   | made, use the time         |
|     |                       | to       | recorded according to the  |
|     |                       | seizure, | following hierarchy:**     |
|     |                       | else go  |                            |
|     |                       | to       | **1. Stroke                |
|     |                       | welldt   | team/neurology**           |
|     |                       |          |                            |
|     |                       |          | **2. ED                    |
|     |                       |          | physician/admitting        |
|     |                       |          | physician**                |
|     |                       |          |                            |
|     |                       |          | **3. ED physician admit    |
|     |                       |          | notes**                    |
|     |                       |          |                            |
|     |                       |          | **4. ED nursing notes**    |
|     |                       |          |                            |
|     |                       |          | **5. EMS**                 |
|     |                       |          |                            |
|     |                       |          | If the time of onset of    |
|     |                       |          | stroke symptoms is not     |
|     |                       |          | clear, enter 99:99.        |
+-----+-----------------------+----------+----------------------------+
| s   | Did the record        | 1,2      | **If a bedside functional  |
| wal | document the result   | ,3,95,99 | swallowing test was        |
| out | of the pre-po intake  |          | performed, the result of   |
|     | dysphagia             | Will be  | the pre-po dysphagia       |
|     | screening/evaluation? | aut      | screen may be taken from a |
|     |                       | o-filled | nursing or clinician note. |
|     | 1\. Okay for patient  | as 95 if | If a radiological or       |
|     | to eat and/or drink   | scrdyspo | instrument exam was        |
|     |                       | = 2, 97, | performed, the result may  |
|     | 2\. Not okay for      | or 99    | be taken from the report   |
|     | patient to eat and/or |          | of the exam, a clinician   |
|     | drink                 |          | note or consult note.**    |
|     |                       |          |                            |
|     | 3\. Result of         |          | **In order to answer "1,"  |
|     | dysphagia             |          | there must be              |
|     | screen/evaluation not |          | documentation indicating   |
|     | documented            |          | that the patient is able   |
|     |                       |          | to eat and/or drink.**     |
|     | 95\. Not applicable   |          |                            |
|     |                       |          |                            |
|     | 99\. Unable to        |          |                            |
|     | determine             |          |                            |
+-----+-----------------------+----------+----------------------------+
| t   | Did the               | 1        | The caregiver is defined   |
| obc | patient/caregiver     | ,2,95,97 | as the patient's family or |
| ess | receive               |          | any other person (e.g.,    |
|     | smoking/tobacco use   | If       | home health) who will be   |
|     | cessation advice or   | smokcigs | responsible for care of    |
|     | counseling during the | = 2,     | the patient after          |
|     | hospitalization?      | will be  | discharge.                 |
|     |                       | aut      |                            |
|     | 1\. Yes               | o-filled | **Adult Smoking            |
|     |                       | as 95    | Counseling:**              |
|     | 2\. No                |          |                            |
|     |                       | If       | Documentation indicating   |
|     | 95. Not applicable    | smokcigs | the patient/caregiver      |
|     |                       | = 1,     | received one of the        |
|     | 97\. Reason           |          | following:                 |
|     | documented by         | 95       |                            |
|     | physician/APN/PA for  | cannot   | -   Direct discussion with |
|     | not providing         | be       |     patient/caregiver to   |
|     | smoking/tobacco use   | entered  |     stop smoking (stop     |
|     | cessation advice or   |          |     using tobacco) whether |
|     | counseling during the |          |     or not the patient is  |
|     | hospitalization       |          |     currently smoking      |
|     |                       |          |                            |
|     |                       |          | -   Viewing a tobacco use  |
|     |                       |          |     cessation video        |
|     |                       |          |                            |
|     |                       |          | -   Given brochure or      |
|     |                       |          |     handouts on tobacco    |
|     |                       |          |     use cessation          |
|     |                       |          |                            |
|     |                       |          | -   Referred to a smoking  |
|     |                       |          |     cessation class or     |
|     |                       |          |     clinic                 |
|     |                       |          |                            |
|     |                       |          | -   Prescribed a smoking   |
|     |                       |          |     cessation aid, e.g.,   |
|     |                       |          |     Habitrol, Nicoderm,    |
|     |                       |          |     Nicorette, Nicotrol,   |
|     |                       |          |     Prostep, or Zyban      |
|     |                       |          |     during hospital        |
|     |                       |          |     admission or at        |
|     |                       |          |     discharge              |
|     |                       |          |                            |
|     |                       |          | -   Prescription of        |
|     |                       |          |     Wellbutrin/bupropion   |
|     |                       |          |     during hospital stay   |
|     |                       |          |     or at discharge, if    |
|     |                       |          |     specifically           |
|     |                       |          |     prescribed as a        |
|     |                       |          |     smoking cessation aid. |
|     |                       |          |                            |
|     |                       |          | If the patient smoked      |
|     |                       |          | within the year prior to   |
|     |                       |          | arrival but does not       |
|     |                       |          | currently smoke, they      |
|     |                       |          | should still be advised    |
|     |                       |          | not to smoke. Cessation    |
|     |                       |          | counseling is still        |
|     |                       |          | required.                  |
|     |                       |          |                            |
|     |                       |          | **Respond "1" if the       |
|     |                       |          | patient/caregiver was      |
|     |                       |          | given advice, a brochure,  |
|     |                       |          | pamphlet, or video         |
|     |                       |          | relative to smoking        |
|     |                       |          | cessation even if the      |
|     |                       |          | patient uses another form  |
|     |                       |          | of tobacco**.              |
|     |                       |          |                            |
|     |                       |          | **If the patient refused   |
|     |                       |          | smoking cessation advice   |
|     |                       |          | or counseling during this  |
|     |                       |          | hospital stay, answer      |
|     |                       |          | "1."**                     |
|     |                       |          |                            |
|     |                       |          | 2 = advice/counseling not  |
|     |                       |          | done, or unable to         |
|     |                       |          | determine from medical     |
|     |                       |          | record documentation       |
|     |                       |          |                            |
|     |                       |          | **Data Sources**:          |
|     |                       |          | Consultation notes,        |
|     |                       |          | Discharge instruction      |
|     |                       |          | sheet, Discharge summary,  |
|     |                       |          | ED record, H&P, Medication |
|     |                       |          | administration record,     |
|     |                       |          | Nursing notes, Progress    |
|     |                       |          | notes, Respiratory therapy |
|     |                       |          | notes, Teaching sheet      |
|     |                       |          |                            |
|     |                       |          | **Exclude:** Any           |
|     |                       |          | documentation dated/timed  |
|     |                       |          | after discharge,           |
|     |                       |          | **except** discharge       |
|     |                       |          | summary and                |
|     |                       |          | oper                       |
|     |                       |          | ative/procedure/diagnostic |
|     |                       |          | test reports (from         |
|     |                       |          | procedure done during      |
|     |                       |          | hospital stay)             |
+-----+-----------------------+----------+----------------------------+
| t   | Enter the date the IV | mm       | If IV t-PA was given at    |
| pad | t-PA was              | /dd/yyyy | another facility and the   |
| ate | administered.         |          | date of administration is  |
|     |                       | <table>  | not found, enter           |
|     |                       | <c       | 99/99/9999.                |
|     |                       | olgroup> |                            |
|     |                       | <col     |                            |
|     |                       | style=   |                            |
|     |                       | "width:  |                            |
|     |                       | 100%" /> |                            |
|     |                       | </c      |                            |
|     |                       | olgroup> |                            |
|     |                       | <tbody>  |                            |
|     |                       | <tr      |                            |
|     |                       | clas     |                            |
|     |                       | s="odd"> |                            |
|     |                       | <        |                            |
|     |                       | td><p>If |                            |
|     |                       | tpagiven |                            |
|     |                       | = 1,     |                            |
|     |                       | &gt;=    |                            |
|     |                       | arrvdate |                            |
|     |                       | and      |                            |
|     |                       | &lt; =   |                            |
|     |                       | a        |                            |
|     |                       | dmdt</p> |                            |
|     |                       | <p>If    |                            |
|     |                       | tpagiven |                            |
|     |                       | = 2,     |                            |
|     |                       | &lt; =   |                            |
|     |                       | 2 days   |                            |
|     |                       | prior    |                            |
|     |                       | to or    |                            |
|     |                       | =        |                            |
|     |                       | a        |                            |
|     |                       | rrvdate< |                            |
|     |                       | /p></td> |                            |
|     |                       | </tr>    |                            |
|     |                       | </tbody> |                            |
|     |                       | </table> |                            |
|     |                       |          |                            |
|     |                       | **Ab     |                            |
|     |                       | stractor |                            |
|     |                       | can      |                            |
|     |                       | enter    |                            |
|     |                       | 99/9     |                            |
|     |                       | 9/9999** |                            |
+-----+-----------------------+----------+----------------------------+
| t   | Enter the time the IV | \_\_\_\_ | Enter the time the IV t-PA |
| pat | t-PA was              |          | was first administered. A  |
| ime | administered.         | UMT      | bolus dose of              |
|     |                       |          |                            |
|     |                       |   ---    | t-PA is usually given,     |
|     |                       | -------- | followed by an infusion.   |
|     |                       | -------- |                            |
|     |                       |          | If IV t-PA was given at    |
|     |                       | If tpagi | another facility and the   |
|     |                       | ven = 1, | time of administration is  |
|     |                       |   \>=    | not found, enter 99:99.    |
|     |                       |   a      |                            |
|     |                       | rrvdate/ |                            |
|     |                       | arrvtime |                            |
|     |                       |   an     |                            |
|     |                       | d \< adm |                            |
|     |                       | dt/admtm |                            |
|     |                       |          |                            |
|     |                       |   ---    |                            |
|     |                       | -------- |                            |
|     |                       | -------- |                            |
|     |                       |          |                            |
|     |                       | **Ab     |                            |
|     |                       | stractor |                            |
|     |                       | can      |                            |
|     |                       | enter    |                            |
|     |                       | 99:99**  |                            |
+-----+-----------------------+----------+----------------------------+
| v   | Was VTE               | 1,2      | **The day of arrival       |
| tem | [me                   |          | counts as hospital day     |
| ech | chanical]{.underline} | If 1,    | 1.**                       |
|     | prophylaxis           | a        |                            |
|     | administered by the   | uto-fill | **Mechanical prophylaxis** |
|     | end of hospital day   | nomecpro | = compression devices or   |
|     | 2?                    | as 95,   | stockings such as          |
|     |                       | else go  | anti-embolism hose used to |
|     | 1\. Yes               | to       | prevent VTE                |
|     |                       | nomecpro |                            |
|     | 2\. No or unable to   |          | **Examples of mechanical   |
|     | determine             |          | prophylaxis such as:**     |
|     |                       |          |                            |
|     |                       |          | **Intermittent pneumatic   |
|     |                       |          | compression devices**      |
|     |                       |          | (IPC): AE pumps            |
|     |                       |          | (anti-embolic pumps)       |
|     |                       |          | calf/thigh, venodynes, DVT |
|     |                       |          | boots-calf/thigh,          |
|     |                       |          | sequential compression     |
|     |                       |          | device (SCD)               |
|     |                       |          |                            |
|     |                       |          | **Graduated compression    |
|     |                       |          | stockings** (GCS) **knee   |
|     |                       |          | or thigh high:**           |
|     |                       |          | Anti-embolism stockings,   |
|     |                       |          | TED hose (TEDS), Jobst     |
|     |                       |          | stockings                  |
+-----+-----------------------+----------+----------------------------+
| wel | Enter the date when   | mm       | **The intent of the        |
| ldt | the patient was last  | /dd/yyyy | question is to determine   |
|     | known to be well (in  |          | when the patient was last  |
|     | his/her usual state   |   --     | known to be well prior to  |
|     | of health) prior to   | -------- | the onset of the current   |
|     | the onset of the      |   \< = 1 | stroke. Last know to be    |
|     | current stroke.       |   month  | well refers to the         |
|     |                       |          | patient's prior baseline   |
|     |                       | prior to | status.**                  |
|     |                       |          |                            |
|     |                       | arrvdate | For example, APN notes,    |
|     |                       |          | "son reports that patient  |
|     |                       | and \< = | was fine after lunch       |
|     |                       |   admdt  | today." Enter that date.   |
|     |                       |          |                            |
|     |                       |   --     | **This question does not   |
|     |                       | -------- | refer to previous health   |
|     |                       |          | conditions which may have  |
|     |                       |          | affected the patient's     |
|     |                       |          | health status.** For       |
|     |                       |          | example, a statement such  |
|     |                       |          | as "patient has not been   |
|     |                       |          | well for 6 months," is not |
|     |                       |          | acceptable for this data   |
|     |                       |          | element.                   |
+-----+-----------------------+----------+----------------------------+
| wh  | Did the               | 1        | **Documentation of an      |
| yno | physician/APN/PA      | ,2,95,99 | allergy to t-PA may be     |
| tpa | document a reason for |          | taken from medical record  |
|     | not administering IV  | Will be  | documentation. Other       |
|     | t-PA for the acute    | aut      | reasons for not            |
|     | ischemic stroke?      | o-filled | administering**            |
|     |                       | as 95 if |                            |
|     | 1\. Yes               | tpagiven | **t-PA must be explicitly  |
|     |                       | = 1 or 2 | documented or clearly      |
|     | 2\. No                |          | implied (e.g.              |
|     |                       | If       | contraindicated) by a      |
|     | 95\. Not applicable   | tpagiven | physician/APN/PA.**        |
|     |                       | = 3, go  |                            |
|     | 99\. Unable to        | to       | **Examples of reasons for  |
|     | determine             | tpartery | not administering t-PA     |
|     |                       |          | include but are not        |
|     |                       |          | limited to:**              |
|     |                       |          |                            |
|     |                       |          | -   CT findings indicate   |
|     |                       |          |     intracranial           |
|     |                       |          |     hemorrhage             |
|     |                       |          |                            |
|     |                       |          | -   Seizure at onset of    |
|     |                       |          |     stroke                 |
|     |                       |          |                            |
|     |                       |          | -   recent major surgery   |
|     |                       |          |     or trauma, within past |
|     |                       |          |     14 days                |
|     |                       |          |                            |
|     |                       |          | -   previous hemorrhagic   |
|     |                       |          |     stroke at any time     |
|     |                       |          |                            |
|     |                       |          | -   history of             |
|     |                       |          |     intracranial           |
|     |                       |          |     hemorrhage/brain       |
|     |                       |          |     aneurysm/vascular      |
|     |                       |          |     malformation/brain     |
|     |                       |          |     tumor                  |
|     |                       |          |                            |
|     |                       |          | -   recent intracranial    |
|     |                       |          |     surgery/head           |
|     |                       |          |     trauma/stroke within   |
|     |                       |          |     the past 3 months      |
|     |                       |          |                            |
|     |                       |          | -   active internal        |
|     |                       |          |     bleeding within past   |
|     |                       |          |     21 days (except        |
|     |                       |          |     menses)                |
|     |                       |          |                            |
|     |                       |          | -   Platelets \< 100,000   |
|     |                       |          |                            |
|     |                       |          | -   Elevated PTT or PT/INR |
|     |                       |          |                            |
|     |                       |          | -   Severe uncontrolled    |
|     |                       |          |     hypertension on        |
|     |                       |          |     presentation           |
|     |                       |          |                            |
|     |                       |          | -   Glucose \< 50 mg/dl or |
|     |                       |          |     \> 400 mg/dl           |
|     |                       |          |                            |
|     |                       |          | -   clinician              |
|     |                       |          |     documentation of late  |
|     |                       |          |     presentation           |
|     |                       |          |                            |
|     |                       |          | -   other                  |
|     |                       |          |                            |
|     |                       |          |    contraindication/reason |
|     |                       |          |     documented by          |
|     |                       |          |     clinician              |
|     |                       |          |                            |
|     |                       |          | -   pregnancy              |
|     |                       |          |                            |
|     |                       |          | -   age \> 75 years        |
|     |                       |          |                            |
|     |                       |          | -   Patient/family refused |
|     |                       |          |     thrombolytics          |
|     |                       |          |                            |
|     |                       |          | -   Comfort measures only  |
|     |                       |          |     documented upon        |
|     |                       |          |     admission              |
|     |                       |          |                            |
|     |                       |          | -   No documented          |
|     |                       |          |     contraindication or    |
|     |                       |          |     unable to determine    |
+-----+-----------------------+----------+----------------------------+
| wh  | Did the               | 1,2,95,  | **Documentation of a       |
| yno | physician/APN/PA      | 98       | reason by a                |
| war | document a            |          | physician/APN/PA for not   |
|     | co                    | Will be  | prescribing an             |
|     | ntraindication/reason | aut      | anticoagulant medication   |
|     | for not prescribing   | o-filled | (warfarin, Coumadin,       |
|     | an anticoagulant      | as 95 if | intravenous heparin, low   |
|     | medication (warfarin, | **d      | molecular weight heparin,  |
|     | Coumadin, intravenous | cthrom3, | or alternative             |
|     | (IV) heparin, low     | d        | anticoagulant) at          |
|     | molecular weight      | cthrom7, | discharge must explicitly  |
|     | heparin, or           | d        | link the noted reason with |
|     | alternative           | cthrom8, | the non-prescription of an |
|     | anticoagulant) at     | or       | anticoagulant medication.  |
|     | discharge?            | dcthrom9 | If the reason is not       |
|     |                       | = 1**    | mentioned in the context   |
|     | 1\. Yes               |          | of not prescribing an      |
|     |                       |          | anticoagulant, do not make |
|     | 2\. No                |          | inferences.**              |
|     |                       |          |                            |
|     | 95\. Not applicable   |          | **Examples of              |
|     |                       |          | anticoagulants:**          |
|     | 98\. Patient refused  |          |                            |
|     | anticoagulant         |          | **Warfarin** such as:      |
|     | medication            |          | Coumadin, Jantoven,        |
|     |                       |          | Panwarfin, Warfilone       |
|     |                       |          |                            |
|     |                       |          | **Intravenous heparin**    |
|     |                       |          |                            |
|     |                       |          | **Low molecular weight     |
|     |                       |          | heparin** (LMWH) such as:  |
|     |                       |          | enoxaparin (Lovenox),      |
|     |                       |          | fragmin, innohep           |
|     |                       |          |                            |
|     |                       |          | **Alternative              |
|     |                       |          | anticoagulants** such as   |
|     |                       |          | danaparoid (Organon),      |
|     |                       |          | hirudin (Lepirudin),       |
|     |                       |          | bivalirudin (Angiomax),    |
|     |                       |          | other heparinoids          |
+-----+-----------------------+----------+----------------------------+
| wic | Were any of the       |          | **To determine the end of  |
| thr | following medications |          | hospital day two, count    |
| om1 | prescribed by the end |          | the arrival date as        |
|     | of hospital day two?  |          | hospital day one. If the   |
| a   |                       |          | medication was prescribed  |
| sad | <table>               |          | on or before 23:59 on      |
| ose | <colgroup>            |          | hospital day two, select   |
|     | <col                  |          | that medication.**         |
| wic | style="width: 38%" /> |          |                            |
| thr | <col                  |          | **3 = Warfarin** such as:  |
| om2 | style="width: 26%" /> |          | Coumadin, Jantoven,        |
|     | <col                  |          | Panwarfin, Warfilone       |
| wic | style="width: 18%" /> |          |                            |
| thr | <col                  |          | **6 = Low dose             |
| om3 | style="width: 17%" /> |          | unfractionated heparin**   |
|     | </colgroup>           |          | (LDUH) -- **only include   |
| wic | <tbody>               |          | heparin administered by    |
| thr | <tr class="odd">      |          | [subcutaneous]{.underline} |
| om4 | <td></td>             |          | route** (SC, SQ, SubQ)     |
|     | <td><strong>Field     |          | LDUH such as: heparin,     |
| wic | Format</strong></td>  |          | calcilean, calciparine     |
| thr | <td><stro             |          |                            |
| om5 | ng>Dose</strong></td> |          | **7 = Intravenous          |
|     | <td><p><strong>F      |          | heparin**                  |
| wic | requency</strong></p> |          |                            |
| thr | <p                    |          | **8 = Low molecular weight |
| om6 | >1,2,3,95,99</p></td> |          | heparin** (LMWH) such as:  |
|     | </tr>                 |          | enoxaparin (Lovenox),      |
| h   | <tr class="even">     |          | fragmin, innohep           |
| epd | <td>1. Aspirin</td>   |          |                            |
| ose | <td><p><st            |          | **9 = Alternative          |
|     | rong>1,2</strong></p> |          | anticoagulants** such as   |
| h   | <p><strong>If 2,      |          | danaparoid (Organon),      |
| epf | auto-fill asadose     |          | hirudin (Lepirudin),       |
| req | as                    |          | bivalirudin (Angiomax),    |
|     | z                     |          | other heparinoids          |
| wic | zzz</strong></p></td> |          |                            |
| thr | <td><p><strong>_ _    |          | **[Dose and frequency of   |
| om7 | _</strong></p>        |          | admi                       |
|     | <table>               |          | nistration:]{.underline}** |
| wic | <colgroup>            |          |                            |
| thr | <col                  |          | -   **Aspirin = If more    |
| om8 | s                     |          |     than one dose of       |
|     | tyle="width: 100%" /> |          |     aspirin is             |
| lm  | </colgroup>           |          |     administered by the    |
| whd | <tbody>               |          |     end of hospital day    |
| ose | <tr class="odd">      |          |     two, enter the largest |
|     | <td>&gt; 0 and &lt;   |          |     dose.** For example,   |
| lm  | 999</td>              |          |     if ASA 81mg is given   |
| whf | </tr>                 |          |     on day 1 and 325 mg is |
| req | </tbody>              |          |     given on day 2, enter  |
|     | </table></td>         |          |     325 mg. Aspirin is     |
| wic | <td></td>             |          |     prescribed as          |
| thr | </tr>                 |          |     milligrams (mg). Dose  |
| om9 | <tr class="odd">      |          |     range may vary from 50 |
|     | <td>2.                |          |     to 325 mg.             |
|     | ASA/dipyridamole      |          |                            |
|     | (Aggrenox)</td>       |          | -   **Low dose             |
|     | <td><str              |          |     unfractionated         |
|     | ong>1,2</strong></td> |          |     heparin(subQ only) =   |
|     | <td></td>             |          |     prescribed as units.** |
|     | <td></td>             |          |     If the low dose        |
|     | </tr>                 |          |     unfractionated heparin |
|     | <tr class="even">     |          |     is ordered to be given |
|     | <td>3. Warfarin       |          |     more than once a day,  |
|     | (Coumadin)</td>       |          |     enter the units        |
|     | <td><str              |          |     ordered per dose. For  |
|     | ong>1,2</strong></td> |          |     example, Heparin 5000  |
|     | <td></td>             |          |     units subQ bid. Enter  |
|     | <td></td>             |          |     5000 for the dose.     |
|     | </tr>                 |          |                            |
|     | <tr class="odd">      |          |     -   **Enter the number |
|     | <td>4. Clopidogrel    |          |         of times a day the |
|     | (Plavix)</td>         |          |         low dose subQ      |
|     | <td><str              |          |         heparin is ordered |
|     | ong>1,2</strong></td> |          |         to be              |
|     | <td></td>             |          |         administered.**    |
|     | <td></td>             |          |                            |
|     | </tr>                 |          | -   **Low molecular weight |
|     | <tr class="even">     |          |     heparin = may be       |
|     | <td>5. Ticlopidine    |          |     prescribed as mg or    |
|     | (Ticlid)</td>         |          |     units.** For example,  |
|     | <td><str              |          |     enoxaprin 30 mg subQ   |
|     | ong>1,2</strong></td> |          |     bid. Enter 30 for the  |
|     | <td></td>             |          |     dose.                  |
|     | <td></td>             |          |                            |
|     | </tr>                 |          |     -   **Enter the number |
|     | <tr class="odd">      |          |         of times a day the |
|     | <td>6. Low dose       |          |         low molecular      |
|     | unfractionated        |          |         weight heparin is  |
|     | heparin               |          |         ordered to be      |
|     | (<strong>subQ         |          |         administered.**    |
|     | only</strong>)</td>   |          |                            |
|     | <td><p><st            |          |                            |
|     | rong>1,2</strong></p> |          |                            |
|     | <p><strong>If 2,      |          |                            |
|     | auto-fill hepdose     |          |                            |
|     | as zzzz, and          |          |                            |
|     | hepfreq as            |          |                            |
|     | 95</strong></p></td>  |          |                            |
|     | <td><p><strong>_ _    |          |                            |
|     | _ _</strong></p>      |          |                            |
|     | <table>               |          |                            |
|     | <colgroup>            |          |                            |
|     | <col                  |          |                            |
|     | s                     |          |                            |
|     | tyle="width: 100%" /> |          |                            |
|     | </colgroup>           |          |                            |
|     | <tbody>               |          |                            |
|     | <tr class="odd">      |          |                            |
|     | <td>&gt; 0 and &lt;   |          |                            |
|     | 9999</td>             |          |                            |
|     | </tr>                 |          |                            |
|     | </tbody>              |          |                            |
|     | </table></td>         |          |                            |
|     | <td></td>             |          |                            |
|     | </tr>                 |          |                            |
|     | <tr class="even">     |          |                            |
|     | <td>7. Intravenous    |          |                            |
|     | (IV) heparin</td>     |          |                            |
|     | <td><str              |          |                            |
|     | ong>1,2</strong></td> |          |                            |
|     | <td></td>             |          |                            |
|     | <td></td>             |          |                            |
|     | </tr>                 |          |                            |
|     | <tr class="odd">      |          |                            |
|     | <td>8. Low            |          |                            |
|     | molecular weight      |          |                            |
|     | heparin</td>          |          |                            |
|     | <td><p><st            |          |                            |
|     | rong>1,2</strong></p> |          |                            |
|     | <p><strong>If 2,      |          |                            |
|     | auto-fill lmwhdose    |          |                            |
|     | as zzzz, and          |          |                            |
|     | lmwhfreq</strong></p> |          |                            |
|     | <p><strong>as         |          |                            |
|     | 95</strong></p></td>  |          |                            |
|     | <td><p><strong>_ _    |          |                            |
|     | _ _</strong></p>      |          |                            |
|     | <table>               |          |                            |
|     | <colgroup>            |          |                            |
|     | <col                  |          |                            |
|     | s                     |          |                            |
|     | tyle="width: 100%" /> |          |                            |
|     | </colgroup>           |          |                            |
|     | <tbody>               |          |                            |
|     | <tr class="odd">      |          |                            |
|     | <td>&gt; 0 and &lt;   |          |                            |
|     | 9999</td>             |          |                            |
|     | </tr>                 |          |                            |
|     | </tbody>              |          |                            |
|     | </table></td>         |          |                            |
|     | <td></td>             |          |                            |
|     | </tr>                 |          |                            |
|     | <tr class="even">     |          |                            |
|     | <td>9. Alternative    |          |                            |
|     | anticoagulants</td>   |          |                            |
|     | <td><str              |          |                            |
|     | ong>1,2</strong></td> |          |                            |
|     | <td></td>             |          |                            |
|     | <td></td>             |          |                            |
|     | </tr>                 |          |                            |
|     | <tr class="odd">      |          |                            |
|     | <td                   |          |                            |
|     | cols                  |          |                            |
|     | pan="4"><p><strong>If |          |                            |
|     | wicthrom1,            |          |                            |
|     | wicthrom2,            |          |                            |
|     | wicthrom3,            |          |                            |
|     | wicthrom4,            |          |                            |
|     | wicthrom5, wicthrom   |          |                            |
|     | 7, wicthrom8, or      |          |                            |
|     | wicthrom9 = 1,        |          |                            |
|     | auto-fill conthrom    |          |                            |
|     | as 95</strong></p>    |          |                            |
|     | <p><strong>If         |          |                            |
|     | wicthrom 3, 6, 7,     |          |                            |
|     | 8, or 9 = 1, go to    |          |                            |
|     | hypoxia, else go to   |          |                            |
|     | norx                  |          |                            |
|     | pro</strong></p></td> |          |                            |
|     | </tr>                 |          |                            |
|     | </tbody>              |          |                            |
|     | </table>              |          |                            |
|     |                       |          |                            |
|     | **Frequency:**        |          |                            |
|     |                       |          |                            |
|     | 1\. Daily             |          |                            |
|     |                       |          |                            |
|     | 2\. Twice a day (bid) |          |                            |
|     |                       |          |                            |
|     | 3\. Three times a day |          |                            |
|     | (tid)                 |          |                            |
|     |                       |          |                            |
|     | 95\. Not applicable   |          |                            |
|     |                       |          |                            |
|     | 99\. None of the      |          |                            |
|     | above or unable to    |          |                            |
|     | determine             |          |                            |
+-----+-----------------------+----------+----------------------------+