Per eCQM specifications numerator includes:

• Inpatient hospitalizations for patients who have documentation of a reason why no VTE prophylaxis was given.
• Reasons for no pharmacological and no mechanical VTE prophylaxis must be explicitly documented by the MD/APN/PA or pharmacist and linked with VTE prophylaxis. Ambulation alone is not a sufficient reason for not administering VTE prophylaxis. In order for ambulation/patient ambulating to be considered as an acceptable reason, there needs to be explicit documentation, e.g., "patient out of bed and ambulating in halls - no VTE prophylaxis needed."

QUESTIONs:

1. Should we use the TJC Specification Manual for STK-1 (linked below) to ensure the above guidance is followed?  https://manual.jointcommission.org/releases/TJC2024A1/DataElem0721.html
2. Should we use the TJC Specification Manual for VTE-6 (linked below) to ensure the above guidance is followed?https://manual.jointcommission.org/releases/TJC2023B1/DataElem0811.html
3. Does this meet criteria for numerator/VTE proph not given:
   1. "Meets low risk criteria-mechanical/pharmacological VT prophylaxis not indicated (eg. ambulating)"