Medical Reason For Not Documenting A Follow Up Plan For Low Or High BMI Union

Data elements that meet criteria using this datatype should document a request to a pharmacy to provide the medication indicated by the QDM category and its corresponding value set.

Timing:

• relevantPeriod addresses the time referenced in the dosage instruction indicating when the medication administration should start and end.
• In the initial publication of QDM 5.5, relevantPeriod referenced the validity period, i.e., the time period for which the ordered supply is authorized by the prescription authorizing the dispensing event.
• For clarification, see Appendix 6.4 with additional guidance for referencing relevantPeriod updating the definition for Medication, Order, "Medication Dispensed", and "Substance, Order".
• author dateTime references the date and time the medication order (prescription) or the reason for not ordering the medication (i.e., negationRationale) is authored.

Notes:

• When calculating cumulative medication duration, the stopTime may be present directly in the medication order. If the stopTime is not available, the duration in days is the difference between the relevantPeriod start and stop times multiplied by (1 + the number of refills).
• negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.

Refer to Special Cases in Appendix A (Section 5.7) for scenarios to consider in calculating cumulative medication duration.

Data elements that meet criteria using this datatype should document a request to a pharmacy to provide the medication indicated by the QDM category and its corresponding value set.

Timing:

• relevantPeriod addresses the time referenced in the dosage instruction indicating when the medication administration should start and end.
• In the initial publication of QDM 5.5, relevantPeriod referenced the validity period, i.e., the time period for which the ordered supply is authorized by the prescription authorizing the dispensing event.
• For clarification, see Appendix 6.4 with additional guidance for referencing relevantPeriod updating the definition for Medication, Order, "Medication Dispensed", and "Substance, Order".
• author dateTime references the date and time the medication order (prescription) or the reason for not ordering the medication (i.e., negationRationale) is authored.

Notes:

• When calculating cumulative medication duration, the stopTime may be present directly in the medication order. If the stopTime is not available, the duration in days is the difference between the relevantPeriod start and stop times multiplied by (1 + the number of refills).
• negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.

Refer to Special Cases in Appendix A (Section 5.7) for scenarios to consider in calculating cumulative medication duration.

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here. 

Timing:

• The relevantPeriod addresses:
  • startTime - The time the encounter began (admission time).
  • stopTime - The time the encounter ended (discharge time).
• author dateTime references the time the action was recorded.
• Refer to the eCQM expression to determine allowable timings to meet measure criteria.

Notes:

• negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
• The locationPeriod is an attribute of the attribute facility location that addresses:
  • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
  • stopTime - the time the patient departed from the location.