SCOPE: All Company-Affiliated Facilities Including, but Not Limited To, Hospitals, Ambulatory

DEPARTMENT: Clinical Services Group – POLICY DESCRIPTION: Core Measure Clarification Core Measures Process Documentation and Education PAGE: 1 of 6 REPLACES POLICY DATED: 11/1/09, 4/1/10 EFFECTIVE DATE: March 1, 2014 REFERENCE NUMBER: CSG.COM.001 (formerly QM.COM.001) APPROVED BY: Ethics and Compliance Policy Committee

SCOPE: All personnel responsible for performing, supervising, monitoring Core Measure abstraction efforts and/or medical record documentation relative to Core Measures within HCA affiliated facilities including, but not limited to, hospitals, hospital-based outpatient surgery departments, and all Corporate Departments, Groups and Divisions.

PURPOSE: The purpose of this policy is to establish processes to clarify incomplete or ambiguous documentation that will be used for Core Measures data abstraction. It also defines when a Core Measure query to a provider will be initiated and outlines the appropriate Core Measure query process to be utilized. It is not to be used for questions involving diagnosis or procedure codes as these are covered under REGS.DOC.002.

POLICY: Appropriate querying will improve the accuracy, integrity, and quality of medical record documentation; minimize variation in the query process; and improve the quality of the physician documentation within the medical record. Company-affiliated facilities will follow appropriate processes to: 1. Initiate queries as appropriate when documentation in the medical record is illegible, incomplete, inconsistent, or unclear for Core Measures data abstraction. 2. Generate a query either concurrently or retrospectively. 3. Obtain documentation related to Core Measures within the guidelines published in the current TJC/CMS Core Measure Specifications Manuals. “The intent of abstraction is to use only documentation that was part of the medical record during the hospitalization (is present upon discharge) and that is present at the time of abstraction. There are instances where an addendum or late entry is added after discharge. This late entry or addendum can be used, for abstraction purposes, as long as it has been added within 30 days of discharge, [Refer to the Medicare Conditions of Participation for Medical Records, 42CFR482.24(c)(2)(viii)], unless otherwise specified in the data element. Documents containing amendments, corrections, or delayed entries must employ the following widely accepted recordkeeping principles (CMS “Medicare Program Integrity Manual” Chapter 3, Section 3.3.2.4): - Clearly and permanently identify any amendments, corrections or addenda; - Clearly indicate the date and author of any amendments, corrections, or addenda; and - Clearly identify all original content. It is not the intent to have documentation added at the time of abstraction to ensure the passing of a measure.” Specifications Manual for National Hospital Inpatient Quality Measures, Introduction to Data Dictionary, Medical Record Documentation, pg. 1-4. 4. Reflect the patient’s clinical picture, care provided, and clinical decision making for the purpose of accurate Core Measures data abstraction. 5. Ensure control processes are implemented to minimize potential compliance risks. 6. Improve the quality of the physician documentation.

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DEFINITIONS: 1. Core Measures - Clinical measures designed to evaluate the processes or outcomes of care associated with the delivery of clinical services; allow for intra- and interorganizational comparisons to be used to continuously improve patient health outcomes; may focus on the appropriateness of clinical decision making and implementation of these decisions; are condition specific, procedure specific, or address important functions of patient care (e.g., medication use, infection control, patient assessment, etc.).

2. Core Measure Clinical Clarification Process - An established mechanism of communication between a Core Measures Professional and Clinical Staff to clarify incomplete and/or ambiguous documentation in the medical record that will be used for the purpose of Core measures data abstraction. a. Concurrent Core Measure Clinical Clarification Process is initiated before the patient is discharged from the facility. b. Retrospective Core Measure Clinical Clarification Process is initiated no more than 30 days after the patient has been discharged from the facility.

3. Clinical Staff includes Nurses, Physicians, Advanced Practice Nurses, Physician Assistants, Nurse Practitioners, Pharmacists, Certified Registered Nurse Anesthetists, Nurse Midwives, Infection Control Practitioners, Licensed Independent Practitioners, Lactation Consultants and others involved in the provision of patient care

4. Providers are Physicians, Advanced Practice Nurses, Physician Assistants, , Certified Registered Nurse Anesthetists , Nurse Practitioners, Licensed Independent Practitioners, and Nurse Midwives

5. Core Measures Professionals include all individuals responsible for performing, supervising, or monitoring Core Measures data abstraction and/or documentation, concurrent review, compliance monitoring, and other activities involved in ensuring hospitals provide and document the provision of care required to meet Core Measures.

6. Core Measure Clinical Clarification Forms - The Company has developed and requires utilization of the approved standardized Core Measures Clinical Clarification Forms which are available in the Meditech QM Module. The approved forms include standardized queries which can be used for clarification of the medical record documentation used in the abstraction of required Core Measures data elements. If clarification is required for a measure with standardized screens, the applicable form within the QM Module and the approved, standardized queries must be used. When clarification is needed for other measures, a general query can be used, adhering to the Clinical Clarification process and query format outlined in this policy. a. Meditech Clinical Clarification Form – a pre-built form containing pre-built standard queries available in the Clinical Clarification Review Types section within the Meditech QM Module b. Core Measure Clinical Clarification Form - a paper form which is acceptable to use during down-time or when the electronic form is otherwise unavailable. See Appendix A 1/2015 DEPARTMENT: Clinical Services Group – POLICY DESCRIPTION: Core Measure Clarification Core Measures Process Documentation and Education PAGE: 3 of 6 REPLACES POLICY DATED: 11/1/09, 4/1/10 EFFECTIVE DATE: March 1, 2014 REFERENCE NUMBER: CSG.COM.001 (formerly QM.COM.001) APPROVED BY: Ethics and Compliance Policy Committee

7. Queries - The Company has developed and requires utilization of the approved standardized queries which can be used for clarification of the medical record documentation used in the abstraction of required Core Measures data elements. If clarification is required for a measure with standardized queries, they must be used. When clarification is needed for other measures, a general query can be used, adhering to the Clinical Clarification process and query format outlined in this policy. a. Meditech Clinical Clarification Queries - pre-built standard queries available in the Clinical Clarification Review Types section within the Meditech QM Module b. Core Measure Clinical Clarification Queries – standard queries which can be copied verbatim onto a paper form which is acceptable to use during down-time or when the electronic form is otherwise unavailable. See Appendix B c. General Queries - free-text question written using the Clinical Clarification process and query format as outlined in the policy. These general, free-text queries can only be used when the question cannot be answered using one of the standard queries.

PROCEDURE: All efforts to clarify incomplete and/or ambiguous documentation as it relates to Core Measure data elements and abstraction within the medical record must be done utilizing the QM Module Clinical Clarification Review Type screens in Meditech. The QM Module Review will produce a Core Measure Clinical Clarification Form for the Provider to document his or her response. When clarification cannot be obtained using the Meditech QM Module, the facility will use the Core Measure Clinical Clarification Form (Paper-version) (See Appendix A). The primary goal is to obtain accurate documentation that is representative of the care provided.

1. Core Measure Clinical Clarification Process Core Measure Professionals responsible for supervising, reviewing and/or abstracting Core Measure documentation must understand and adhere to the following requirements: a. Core Measure clinical clarifications can be initiated either concurrently or retrospectively as an established mechanism of communication between a Core Measure Professional and Provider to clarify documentation in the medical record. b. Core Measure clinical clarifications can be sought when the documentation of the clinical picture of the patient indicates a clinical core measure was considered or addressed, or a condition was present, but the Provider has not specifically or clearly documented the clinical decision-making process within the medical record. c. The selection of the appropriate data element requiring clinical clarification will be determined based on the incomplete and/or ambiguous documentation. The General Clinical Clarification queries should only be used when clarification cannot be obtained using the pre-built Meditech Clarification Queries in the QM Module. For a complete listing of the pre-built queries, refer to the QM Module Patient Review Types within Meditech or refer to the listing provided within the Screens section of the “Core Measure Clarification Process Administrator’s Guide” available on Atlas (http://atlas2.medcity.net/portal/site/atlas). d. The Core Measure Clinical Clarification Form must be used each time clarification of Core Measure

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documentation during an inpatient hospitalization or outpatient encounter is initiated. e. Each Meditech Clinical Clarification Form can include multiple queries, but a separate Clinical Clarification Form must be used each time a new clarification process is initiated. f. Clinical Clarification Forms in the Paper version only allow for one query per form. When more than one query is necessary, a separate form is required for each one. g. When the clarification process is initiated verbally, it must subsequently be documented in writing using a Core Measure Clinical Clarification Form. h. It is not acceptable for a Core Measures Professional to document a verbal response from the Provider on a Core Measure Clinical Clarification Form. i. Communication must clarify that the request, even if asked verbally, will require the Provider’s signature and will be included within the medical record. j. It is not acceptable for a Core Measures Professional to make repeated attempts to obtain clarification with the intent only to receive a particular outcome.

2. Response from the Provider The Core Measure Clinical Clarification Form must be signed, dated, and timed. If no additional documentation is provided in response to a Core Measure Clinical Clarification Form, the Provider is required to sign and date the form indicating there is no additional information.

3. Inclusion and Maintenance in the Permanent Medical Record a. The completed Core Measure Clinical Clarification Form is considered to be a physician’s progress note regardless of the addition or absence of additional documentation. b. There may be instances when the response is received outside the specific timeframes for utilization within the Core Measure abstraction process. When this occurs, the form will be maintained in the Physician Progress Notes section of the permanent medical record, but will not be used for the purpose of Core Measures data abstraction. c. The Core Measure Clinical Clarification Form must be maintained in the Physician Progress Notes section of the medical record regardless of the addition or absence of additional documentation.

4. Facility Responsibilities a. Medical Staff Approval Process The facility must submit the standardized Core Measure Clinical Clarification Form for approval following the process outlined in hospital policy, medical staff bylaws, or rules and regulations for adding forms to the medical record. b. Administration and Medical Staff Support Administration and medical staff must support this processs to ensure its success. It is the responsibility of each facility’s administration to ensure that this policy is applied by all individuals involved in Core Measure abstraction and documentation. c. Education and Tracking 1) All facilities should educate their physicians and Core Measures Professionals on the importance

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of concurrent documentation within the body of the medical record. 2) Communication must be provided to the medical staff that Core Measures Professionals will initiate requests to support accurate and complete documentation in the medical record. 3) The Quality Director or designee is responsible for holding the hospital’s Core Measures Professionals accountable for the annual review and compliance with the policies, tools and resource documents. 4) Clinical Clarification tracking and trending must be performed and trends assessed, at a minimum, on an annual basis to identify ongoing educational and documentation needs of the medical/clinical staff. 5) The Quality Director or designee must complete an annual review to confirm adherence with this policy and provide verification to CSG that his or her hospital’s COMET Users have completed the annual review by the deadline set by CSG.

5. Corporate Responsibilities a. CSG will review the tools and resources as appropriate to include any regulatory requirements on a quarterly basis. b. Deadlines for the annual review will be communicated via e-mail. c. Any revisions to the mandatory education will be communicated via e-mail. d. CSG will monitor the participation and completion of the hospital’s mandatory education.

6.Maintenance of the Meditech Core Measure Clinical Clarification Tool and Documentation The CSG Clinical Analytics Department in cooperation with IT&S will update the HCA Core Measure Clinical Clarification Process Tools and the associated Meditech queries with each new Core Measure specification manual release.

7.Questions and Concerns related to the Core Measures Clinical Clarification Process All day-to-day operational issues should be handled locally at the facility working collaboratively with one’s direct supervisor and/or facility Ethics and Compliance Officer. a. For unresolved or unanswered general questions regarding operations or implementation of the CSG.COM policies, please contact the CSG Manager of Clinical Operations, Clinical Analytics, or COMET Support. b. Each colleague has an individual responsibility for reporting any activity by any colleague, physician, subcontractor, or vendor that appears to violate applicable laws, rules, regulations, accreditation standards, and standards of medical practice, Federal healthcare conditions of participation, or the HCA Code of Conduct. c. If a matter that poses serious compliance risk to the organization is reported locally, and if the reporting individual doubts that the issue has been given sufficient or appropriate attention, the individual should report the matter to higher levels of management or the Ethics Line (1-800-455- 1996) until satisfied that the full importance of the matter has been recognized. d. For questions involving diagnosis or procedure codes, refer to Coding /HSG Policy REGS.COD.002.

1/2015 DEPARTMENT: Clinical Services Group – POLICY DESCRIPTION: Core Measure Clarification Core Measures Process Documentation and Education PAGE: 6 of 6 REPLACES POLICY DATED: 11/1/09, 4/1/10 EFFECTIVE DATE: March 1, 2014 REFERENCE NUMBER: CSG.COM.001 (formerly QM.COM.001) APPROVED BY: Ethics and Compliance Policy Committee

REFERENCES: 1. Medicare Conditions of Participation, 42CFR482.24(c) (2) (viii) 2. CMS Medicare Bulletin - GR 2007-03 3. The Joint Commission/CMS Specification Manual for National Hospital Inpatient Quality Measures 4. The Joint Commission Data Quality Manual 5. Documentation Improvement (DI) – Compliance Requirements Policy, REGS.DOC.001 6. Query Documentation for Clinical Documentation Improvement (CDI) & Coding – Compliance Requirements, REGS.DOC.002 7. Correction of Noneditable Core Measure Data Elments in COMET Policy. CSG.COM.002 8. Purging of COMET Core Measure Records Policy, CSG.COM.003

APPENDIX

Appendix A - See attached Core Measure Clinical Clarification Form (Paper-version) Appendix B – See attached Core Measure Clinical Clarification Queries

1/2015 APPENDIX A Core Measure Clinical Clarification Form (Paper-version)

This form is to be used when the Meditech QM module is not available. This form is an established mechanism of communication between the Provider and the Core Measure Professional and is used to clarify incomplete and/or ambiguous documentation in the medical record. The fact that a question is asked does not imply that any particular answer is desired or expected. Thank you for your assistance in clarifying this documentation.

Dear Dr.: ______Today’s Date: ______

Re:______who was admitted on ______(Patient Name) (Admission Date)

Please respond to the following question . (Note: For a listing of pre-built questions reference the Screens section of the “Core Measures Clarification Process Administrator’s Guide” available on Atlas.)

Clarification is needed for the following medical record documentation: Documentation Source (H&P, progress note, etc.) Date(s)

Provider completes this section: Please provide any additional documentation in response to the question stated above or check applicable box below.

Additional information entered in medical record No additional information

______PROVIDER SIGNATURE DATE TIME

Thank you for your consideration of the query. In responding to this query, please exercise your independent professional judgment. If you have any questions, please utilize the contact name below.

Contact Name: ______Phone Number: ______Fax Number: ______

General Clinical Clarification Form (effective date 03/01/14) Patient Name: ______Admit Date: ______D/C Date:______MR#: ______Acct #: ______APPENDIX A THIS FORM IS CONSIDERED A PHYSICIAN PROGRESS NOTE AND SHOULD BE MAINTAINED IN THE PERMANENT MEDICAL RECORD. APPENDIX B Core Measure Clinical Clarification Queries When one of the data elements below requires initiation of the Core Measure Clinical Clarification Process and the facility does not have access to the Meditech QM Module, the standard queries should be used. This standard verbiage meets the criteria as set forth in the Core Measure Clinical Clarification Policy and should not be altered. A General Clinical Clarification form using free-text should only be used when the answer cannot be obtained using the appropriate query below Note: This same information is available on Atlas within the document entitled "Core Measures Clarification Process Administrator's Guide" which is updated annually by HCA IT&S and CSG.

Acute Myocardial Infarction (AMI) Core Measure Data Element Verbiage for Clarification of Data Element Clinical Trial The ______section of the patient’s medical record reflects that the patient may have been on a Clinical Trial studying patients with acute myocardial infarction (AMI), ST-elevation myocardial infarction (STEMI), Non ST-elevation MI (NSTEMI), heart attack, or acute coronary syndrome (ACS). If yes, please provide a copy of the signed consent form for the clinical trial. First ECG Interpretation The ______section of the patient’s medical record is unclear if the patient had ST-segment elevation on the initial ECG. Please clarify. Reason for Delay in Fibrinolytic Therapy The ______section of the patient’s medical record reflects a delay in administration of fibrinolytics (administered > 30 minutes after arrival). Please clarify in the Discharge Summary if the hold, delay, deferral, or wait was related to need to wait for consult with another specialist or other non-system reason. Transfer from Another Hospital or ASC The patient’s medical record reflects that the patient may have been received as a transfer from an inpatient, outpatient, or emergency/observation department of an outside hospital or an ambulatory surgery center. Please clarify.

Surgical Care Improvement Project (SCIP) COMET Data Element On-screen Description text within Meditech Clinical Trial The ______section of the patient’s medical record reflects that the patient may have been on a Clinical Trial relevant to one or more of the SCIP measures. If yes, please provide a copy of the signed consent form for the clinical trial.

Immunization (IMM) Core Measure Data Element Verbiage for Clarification of Data Element Influenza vaccine status The patient’s medical record does not indicate if this patient has been given a flu vaccine during this flu season. Please clarify if the patient has been given a flu vaccine during this flu season or the patient is up to date on all vaccines.

1 APPENDIX B

Stroke (STK) COMET Data Element Verbiage for Clarification of Data Element Anticoagulation Therapy Prescribed At The ______section of the patient’s medical record reflects Discharge that the patient may have been prescribed an anticoagulant at discharge. Please clarify in the Discharge Summary if the patient was prescribed an anticoagulant or there was a reason for not prescribing one at discharge. Antithrombotic Therapy Prescribed At The ______section of the patient’s medical record reflects Discharge that the patient may have been prescribed an antithrombotic at discharge. Please clarify in the Discharge Summary if the patient was prescribed an antithrombotic or there was a reason for not prescribing one at discharge. Assessed for Rehabilitation Services The ______section of the patient's medical record reflects that the patient may have received a rehabilitation assessment or services during this hospitalization or was referred for rehabilitation services following discharge. Please clarify. Atrial Fibrillation/Flutter The ______section of the patient's medical record reflects that the patient may have a history or current finding of atrial fibrillation/flutter. Please clarify. Clinical Trial The ______section of the patient’s medical record reflects that the patient may have been on a Clinical Trial studying patients with Stroke. If yes, please provide a copy of the signed consent form for the clinical trial. Comfort Measures Only The ______section of the patient’s medical record reflects that comfort care may have been discussed or recommended. Please clarify. Discharge Disposition The ______section of the patient’s medical record is unclear about the patient's Discharge Disposition. Please clarify the final place or setting to which the patient was discharged on the day of discharge. Elective Carotid Intervention The ______section of the patient's medical record reflects that this admission may have been for the sole purpose of an elective carotid intervention. Please clarify. IV OR IA Thrombolytic (t-PA) Therapy The ______section of the patient's medical record Administered at This Hospital or Within 24 reflects that the patient may have received intravenous (IV) or intra- Hours Prior to Arrival arterial (IA) thrombolytic therapy (t-PA) within 24 hours prior to arrival. Please clarify. LDL-c Greater Than or Equal to 100 mg/dL The ______section of the patient’s medical record reflects that the patient may have had LDL-c testing done within 30 days prior to hospital arrival which showed an LDL-c direct or calculated value of greater than or equal to 100mg/dL. Please clarify. Pre-Arrival Lipid Lowering Agent The ______section of the patient’s medical record suggests that the patient may have been on a lipid lowering agent prior to this hospitalization. Please clarify. Reason for Oral Factor Xa Inhibitor The ______section of the medical record reflects that the patient may have received Oral Factor Xa Inhibitor for VTE Prophylaxis due to a history or current finding of atrial fibrillation or flutter, hip or knee replacement surgery, or VTE treatment. Please clarify. Statin Medication Prescribed at Discharge The ______section of the patient's medical record reflects that the patient may have been prescribed a statin at discharge. Was the patient prescribed a statin at discharge? Please clarify in the Discharge Summary if the patient was prescribed a statin or there was a reason for not prescribing one at discharge. 2 APPENDIX B

Inpatient Emergency Department (ED) COMET Data Element Verbiage for Clarification of Data Element Decision to Admit Time The time the decision was made to admit the patient to an inpatient bed is unclear in the Emergency Department Record. If known, please clarify in the ED record the time the decision was made to admit the patient to an inpatient bed.

Venous Thromboembolism (VTE) COMET Data Element Verbiage for Clarification of Data Element Clinical Trial The ______section of the patient’s medical record reflects that the patient may have been on a Clinical Trial studying patients with venous thromboembolism (VTE) (prevention or treatment interventions). If yes, please provide a copy of the signed consent form for the clinical trial. Comfort Measures Only The ______section of the patient’s medical record reflects that comfort care may have been discussed or recommended. Please clarify. Discharge Disposition The ______section of the patient’s medical record is unclear about the patient's Discharge Disposition. Please clarify the final place or setting to which the patient was discharged on the day of discharge. Parenteral Anticoagulation Prescribed at The ____ section of the patient's medical record reflects that the patient Discharge may have been prescribed parenteral (intravenous [IV] or subcutaneous [sub cu]) anticoagulation therapy at discharge. Please clarify if one was prescribed, and if one was prescribed, note the name of the medication. Reason for Discontinuation of Parenteral The ______section of the patient's medical record reflects that Therapy parenteral (intravenous [IV] or subcutaneous [sub cu]) anticoagulation therapy was discontinued. Please clarify in the Discharge Summary if the VTE treatment was to be provided with an Oral Factor Xa Inhibitor or if there is another reason for discontinuing the parenteral therapy. Reason for Oral Factor Xa Inhibitor The ______section of the medical record reflects that the patient may have received Oral Factor Xa Inhibitor for VTE Prophylaxis due to a history or current finding of atrial fibrillation or flutter, hip or knee replacement surgery, or VTE treatment. Please clarify. VTE Confirmed The ______section of the patient's medical record reflects that the patient may have had a confirmed VTE. Please clarify. Warfarin Prescribed at Discharge The ______section of the patient's medical record reflects that warfarin may have been prescribed at discharge. Please clarify.

Children's Asthma Care (CAC) COMET Data Element Verbiage for Clarification of Data Element Clinical Trial The ______section of the patient’s medical record reflects that the patient may have been on a Clinical Trial studying pediatric patients with Asthma. If so, please provide a copy of the signed consent form for the clinical trial. Discharge Disposition The ______section of the patient’s medical record is unclear about the patient's Discharge Disposition. Please clarify the final place or setting to which the patient was discharged on the day of discharge.

Perinatal Care (PC)

3 APPENDIX B COMET Data Element Verbiage for Clarification of Data Element Antenatal Steroid Therapy Initiated The ______section of the medical record reflects antenatal steroids may have been initiated prior to arrival in another setting of care, i.e., doctor's office, clinic, birthing center. Please clarify. Clinical Trial The ______section of the patient’s medical record reflects that the patient may have been on a Clinical Trial. If yes, please provide a copy of the signed consent form for the clinical trial. Discharge Disposition The ______section of the patient’s medical record is unclear about the patient's Discharge Disposition. Please clarify the final place or setting to which the patient was discharged on the day of discharge. Reason for Not Exclusively Feeding Breast The ______section of the patient's medical record reflects Milk that there may have been a maternal medical condition contraindicating exclusively feeding the newborn breast milk during the hospital stay. Please clarify. Labor The ______section of the medical record reflects the patient may have been in labor at the time of admission. Please clarify. Parity The ______section of the patient's medical record is unclear about the number of deliveries, whether resulting in live or stillborn infants, the patient experienced prior to current hospitalization. Please clarify. Prior Uterine Surgery The ______section of the medical record reflects the patient may have had prior uterine surgery. Please clarify. Reason for Not Initiating Antenatal Steroid The ______section of the patient's medical record Therapy reflects that there may have been a reason for not initiating antenatal steroid therapy. Please clarify. Spontaneous Rupture of Membranes The ______section of the medical record reflects the patient’s membranes may have been ruptured at the time of admission. Please clarify.