Memo - Aspirin Administration Documentation

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Aspirin administration documentation

2010-12-01

Clear documentation of aspirin administration or withholding is required on ALL suspected cardiac, acute coronary syndromes, and STEMIs.

EFFECTIVE IMMEDIATELY: All incidents where there is a suspicion of a cardiac event, ACS or STEMI must have the following documentation in the report:

  • Aspirin administered – time given, route and dose.
  • If aspirin is withheld – must clearly document the reason why it was not given. Examples include (but not limited to) when the patient:
    • Reports that he/she took aspirin as directed by the 911 dispatcher (this is part of their pre-arrival instructions)
    • Reports taking a dose of aspirin within the last 4 hours (document dose taken)
    • Advises he/she has an allergy to aspirin
    • Reports having a recent surgery (less than 30 days)
    • States a history of bleeding ulcers
    • States he/she is taking Coumadin or other anticoagulants
    • Reports a history of low platelets or a bleeding disorder

The use and documentation of aspirin in ACS is a mandatory reporting requirement and standard of care in cardiac events. Our documentation must be very clear in this area. As a reporting requirement it will be continually monitored for quality improvement process.

As always - thank you for the excellent work that you do.

Sincerely;

T.M. Husty, DO Medical Director