Venous Thromboembolism Discharge Instructions

Last updated: May 3, 2018

CMS Measure ID: CMS110v3
Version: 3
NQF Number: None
Measure Description:

This measure assesses the number of patients diagnosed with confirmed VTE that are discharged to home, home care, court/law enforcement or home on hospice care on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring, and information about the potential for adverse drug reactions/interactions.

Initial Patient Population:

Patients age 18 and older discharged from hospital inpatient acute care with a diagnosis of venous thromboembolism (VTE)and a length of stay less than or equal to 120 days.

Denominator Statement:

Patients with VTE confirmed through a diagnostic test and discharged to home or court/law enforcement on warfarin therapy.

Denominator Exclusions:


Numerator Statement:

Patients with documentation that they or their caregivers were given written discharge instructions or other educational material about warfarin that addressed all of the following:

  1. compliance issues
  2. dietary advice
  3. follow-up monitoring
  4. potential for adverse drug reactions and interactions
Numerator Exclusions:

Not Applicable

Denominator Exceptions:


Measure Steward: The Joint Commission
Domain: Person and Caregiver-Centered Experience Outcomes
Short Name: VTE5
Next Version:
Measure Score: Proportion
Score Type: Process
Improvement Notation:

An increase in rate


The unit of measurement for this measure is an inpatient episode of care. Each distinct hospitalization should be reported, regardless of whether the same patient is admitted for inpatient care more than once during the measurement period. In addition, the eMeasure logic intends to represent events within or surrounding a single occurrence of an inpatient hospitalization.

Written information given to the patient is required to address each and every one of the educational components. Thes components are modeled in the population criteria and data criteria as communication from provider to patient: adverse reactions and interactions, INR monitoring and medication compliance, dietary advice and follow-up monitoring, and are intended to be specific to discharge instructions for warfarin therapy. The educational components are intended as discharge instructions and not as verbal education.


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