Antithrombotic therapy not prescribed for documented reasons (e.g., patient had stroke during hospital stay, patient expired during inpatient stay, other medical reason(s)); (e.g., patient left against medical advice, other patient reason(s))
HCPCS code
Name of the Procedure:
Antithrombotic Therapy Not Prescribed for Documented Reasons (HCPCS G8697)
Summary
Antithrombotic therapy involves medications that prevent blood clots. Sometimes, this therapy is not prescribed due to specific documented reasons like a patient having a stroke during their hospital stay or expiration during the inpatient stay. Other reasons include medical contraindications or the patient leaving against medical advice.
Purpose
To document the reasons for not prescribing antithrombotic therapy in patients. The goal is to ensure medical records accurately reflect the rationale behind withholding the therapy, thereby aiding in patient safety and care quality.
Indications
- Patient experienced a stroke during the hospital stay.
- Patient expired during the inpatient stay.
- Medical contraindications (e.g., risk of bleeding).
- Non-compliance or refusal of treatment by the patient.
Preparation
No specific preparation is required as this is a documentation process rather than a clinical procedure.
Procedure Description
- Medical Evaluation
- Assess the patient and determine whether antithrombotic therapy is appropriate.
- Documentation
- Clearly document the reasons for not prescribing antithrombotic therapy in the medical records.
- Communication
- Ensure the patient and family are informed about the decision and the reasons behind it.
Tools, equipment, or technology used include electronic health records (EHR) for documentation. No anesthesia or sedation is involved.
Duration
The documentation process typically takes a few minutes.
Setting
This is done in any healthcare setting where patient care is provided, such as hospitals, outpatient clinics, or surgical centers.
Personnel
Healthcare professionals involved include physicians, nurses, and medical record personnel.
Risks and Complications
- Incomplete Documentation: Risk of failing to capture the reasons accurately, affecting patient care continuity.
- Miscommunication: Misunderstanding between healthcare providers or with the patient/family.
Benefits
- Improved Patient Safety: Ensures appropriate clinical decision-making.
- Quality Assurance: Helps in audit trails and quality improvement efforts.
- Benefits are immediate as they improve the transparency and accuracy of patient care records.
Recovery
No physical recovery is needed as this is a documentation process.
Alternatives
No alternatives are required since this is a non-clinical documentation process.
Patient Experience
Patients might feel reassured knowing that their care decisions are well-documented and communicated. Pain management and comfort measures are not applicable here as no physical procedure is involved.