Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

QuestionSorted ascending Related to
STK-6 Data Entry in CMIP for Q1 2010 STK
For Q1 2013 fVTE and Oral Factor Xa inhibitor in Stroke patients. STK-01
in 2016, will the vendors still be able to submit STK HCD for STK Certification for our hospitals? STK
Abstraction for Clinical Trial (STK ) STK
ABstraction for Date Last Known Well STK
Abstraction for Last Known Well STK-04
Abstraction Tools ASR-OP-1
activity charting ACHF
Activity specifics ACHF
Admission Date STK-01
Admitted for elective carotid intervention STK
AMA and Number of Antipsychotic Meds Prescribed at Discharge HBIPS-4, HBIPS-5
Antithrombotic Administration after t-PA STK-05
Appointment for Follow Up/ Release of Information HBIPS, HBIPS-7
Appropriate Justification for Multiple Antipsychotic Meds at DC - Rationale for Allowable Value 4 HBIPS
Are MRI reports an acceptable data source for Evidence of Atherosclerosis? STK-06
Are patients admitted for elective basilar stenting excluded from the stroke chart audits? STK
Are patients that stroke while an inpatient included in the measure population? STK
Are patients who have ischemic stroke occured after hospital arrival included in CSTK-01 population CSTK-01
Are retired Stroke Core Measures still required for comprehensive stroke centers? STK
Are the following examples acceptable Reasons for Not Prescribing Anticoagulation and Antithrombotic Therapy at Discahrge? STK, STK-02
Arrival time Abstraction. CSTK-11
Arrival Time for STK, CSTK and STK-OP Measures STK
Arrival time for transferred patients CSTK-07
Assessed for Rehabaliitation Services STK-10
Assessed for Rehabilitation STK
Birth Weight suggested Sources PC-06
Can a patient undergoing Cardiac Surgery who received RBC's, FFP and Platelets be counted for more than one measure? BM
Can an addendum be added to the medical record? STK-01
Can an addendum be made to a pt's chart that has been d/c - Physician did not place the hunt & hess. CSTK
Can documentation on a pre-printed stroke order form for VTE Prophylaixs be used as a sufficient reason for no prophylaxis? STK-01
Can estimated blood loss (EBL be used for the data element pre-transfusion hemoglobin/hematocrit.) BM-02
Can I use VTE used during the Observation, given prior to hospital admission STK-1
Can post discharge documentation of a statin prescription be used in abstraction? STK-06
Can the following note be used as a Reason for Not Prescribing Anticoagulation Therapy? STK-03
can we accept a Drs documentation that it is not a hemorragic transformation CSTK, CSTK-05
Can we use E/M code 99211? ACHF
Clairfy time to recanalization CSTK, CSTK-07
Clarification of CSTK-1 Measure Population Requirements CSTK-01
Clarification of data elements needed CSTK-05b, CSTK-07
Code 433.10 and Transient Ischemic Attack STK
Comparative Data for Stroke Measures STK
Comprehensive Stroke (CSTK Sub-Populations) CSTK
Consideration of PRADAXA as anticoagulation therapy for patients with atrial fibrillation STK-03
Continuing Care Plan - Reason for Hospitalization HBIPS
Continuing Care Plan Document Questions HBIPS
Continuing Care Plan-Discharge Medications Indications for Use HBIPS
COVID-19 CSTK
CSTK 02, 05, and 06 Measures CSTK-01, CSTK-02, CSTK-05, CSTK-06
CSTK 3 CSTK, CSTK-03
CSTK 4 Denominator Population CSTK-04
CSTK Procedure Times CSTK
CSTK-01 Procedures and Timing 1 calculation CSTK-01
CSTK4 documentation time? CSTK-04
Dabigatran (PRADAXA use in Stroke Patients) STK
Data Abstraction for "Last Known Well" STK
Data abstraction for VTE Prophylaxis when administered prior to admission STK
Data Element Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD at Discharge has an incomplete sentence ACHF-01
Data Element- Violence Risk to Self HBIPS
Date Last Known Well STK
Date/Time of First Pass for CSTK-7 CSTK
Define who is considered a stroke team for STK 4. STK
Definition of validated and non-validated screening tool for substance use SUB-01
Denominator exclusion population ICD-9 CM diagnosis codes CSTK, CSTK-03
Dietary Advice "consistent amount" of foods with Vitamin K rather than avoidance should be advised. VTE-05
Discharge Code and Transfers of Patients STK-OP
Discharge Instructions for Activation of Emergency Medical System (EMS (911)) STK-08
Discharge Medications and Indication for Use HBIPS-6, HBIPS-7
Discharged on Anticoagulation Therapy STK
Do we need to collect 90 day mRS on pts undergoing CEA/CAS? CSTK
Documentation added to D/C summary after discharge STK-6
Documentation Compliance for IV t-PA STK, STK-04
Documentation for Rehabilitation Assessment STK-10
Documentation for Stroke Education HF-1
Documentation for tPA exclusion STK, STK-04
Documentation of Last Known well STK, STK-4
Documentation of Stroke Education STK-08
Documentation ofJustification for Multiple Antipsychotic Medications HBIPS
Documention of Stroke education at discharge, STK-08
Does a hold on anticoagulation count as a valid reason for not prescribing at discharge? STK-03
Does all medical record documentation need to be dated and timed? STK
Does Appendix H, Table 2.2 exclude ambulatory stroke patients from the VTE prophylaxis? STK
Does CSTK - 03 include directly admitted transfers (that bypass ED?) CSTK-03
Does the following documentation meet education regarding Risk factors for stroke? STK
Does the reason for not presciribing anticoagulation therapy have to be documented on the dau of discharge? STK-03
doucumentation of ich and hunt hess CSTK-03
DVT Prophylaxis and Ambulation STK, STK-01
Earliest Aneurysm Repair or Surgical Interv Procedure Time CSTK
Earliest principal procedure time/first pass time CSTK
Earliest Reperfusion Procedure Date/Time for transferred patients CSTK-01
EF on admission 15%. Day of discahrge EF 50-55% per ECHO. Do we answer Y for LVSD<40 . ACHF
Elective Carotid Intervention STK
Elective carotid intervention documentation STK
Evidence of Atherosclerosis STK
Exclusive breast milk feeding definition PC
Expired after discharge CSTK-02
Failed attempt at thrombectomy CSTK-08
Failed Attempt at Thrombectomy CSTK-08, CSTK-11, CSTK-12
First NIHSS performed days after admission CSTK-01
First Pass of a Mechanical Reperfusion Device / First Pass Time CSTK, CSTK-05
First Radiographic Image, CSTK 07 STK
Follow-up to UserQuestion102705 CSTK
Follow-up to UserQuestionId03Stk100628 STK
Follow-up to UserQuestionId03Stk100984 STK-04
Follow-up to UserQuestionId03Vte101043 VTE-05
Footling breech code 652.81 as an exclusion for PC-02 PC-02a
For patients transfused in Operating Room, how do we respond if there is no "written" order for transfusion. BM-05
Functional Status at Discharge ACHF
Graduated Compression Stocking (GCS) STK
Graduated Compression Stockings as VTE Prophylaxis for Stroke Patients (STK-1) VTE-01, STK-1
HBIPS Discharge Status HBIPS
HBIPS Event Dates Prior to Admission HBIPS
HBIPS- Restraint and Seclusion in ED HBIPS-3
HBIPS-1 Timeframe for Screening Questions HBIPS
History of low vertical incision documented BUT no documentation of classical incision. PC-01
How is Length of Stay (LOS calculated for STK-1?) STK-01
How should Last Known Well be abastracted when there is conflicting documentation in the medical record? STK-04
How should we abstract pharmacological VTE prophylaxis when the patient is NPO? STK
How should we abstract thrombolytic administration in the 3 to 4.5 hr timeframe when a reason for not administering existed within 3 hrs? STK, STK-04
How to abstact Last Known Well when there is too much information? STK
How to Answer Questions on Advanced Stroke Tab Intent to Perform MER CSTK-08
Hunt & Hess/ ICH score documentation required by tele neuro radiology prior to transfer STK
Hunt and Hess & ICH Score Documentation CSTK-03
ICD-9-CM Code 433.10 STK
ICH score documentation CSTK-03b
If a physician writes an order for SCDs, is this sufficient to select 'Yes' for VTE Prophylaxis? STK-01, VTE-01
If the admitting diagnosis is not stroke, can the case be excluded from STK-4? STK-04
If the patient enters the ED as a potential or actual TIA or hemorrhagic stroke patient, are the ED physicians required to document why the patient did not have IV thrombolytics initiated? STK
If tPA is given at an outside hospital by our Critical Transport Team, should we take credit? STK, STK-04
Importance of exclusive breast milk feeding PC
In the Operating Room, is "Estimated Blood Loss" for PRBC'S considered transfusion criteria? BM-02
Initial Blood Pressure at Hospital Arrival Field Format CSTK-03
Initial Date/time of NIHSS teleneurologist CSTK, CSTK-01
Inter-rater Reliability and Chart Re-asbstraction STK
Is admission day counted as day 1 for STK-1? STK
Is full medication reconciliation required by PSCs to meet the Medication Education measure component? STK-08
Is heparin 5000U SQ acceptable for antithrombitic administered by end day 2 STK
Is intensive dosing of statin required to meet STK-6? STK
Is it considered CMO if the palliative care consult was done and the patient refuses palliative care the next day? STK
Is refusal of all IV's a Reason for Not Initiating IV Throbolytic Therapy? STK-04
Is the ambulatory patient considered low risk for VTE? STK
Is there benchmark data available for HBIPS Data? HBIPS, HBIPS-1, HBIPS-1b, HBIPS-1c, HBIPS-1d, HBIPS-1e
Is this considered a stroke clinical trial patient? STK
Is Xarelto (Rivaroxaban an acceptable anticoagulant for STK-3?) STK-03
Is Xarelto an antithromotic for use in Stroke? Can it be used for antithrombotic med at discharge? STK, STK-02
IV Alteplase STK-OP
Jan 2012 Follow-up monitoring VTE-05
Last Known Well STK, STK-04
Last Known Well STK-04
Last Known Well Version 5.2 STK-4
Last known well when symptoms resolve then reoccur STK
Last Known Well Y/N? STK-4
Late Coded Stroke STK-4 and STK-5 STK, STK-4
LDL Measured within first 48 hrs or 30 days prior to hospital arrival STK
Lovenox 40mg daily - Antithrombotic Therapy Administered by End of Hospital Day Two STK
Lovenox in reference to STK-2, STK-5, and STK-3 STK-2, STK-3, STK-5
MER Attempted During this Encounter - Clot Dissolved CSTK-11
MER code for combined billing for two hospitals-TSC CSTK, CSTK-08
MER Eligibility CSTK
Mother's choice not to breast feed PC-05
mRS CSTK
Multiple EMRs HBIPS
Multiple Procedure Times CSTK, CSTK-01
Multiple TICI reperfusion grades CSTK-08
Must the patient refuse both pharmacological and mechanical VTE prophylaxis to count as a reason for no prophylaxis? STK-01
Need information about the required import file specifications BM
Next Level of Care Provider Same as Hospital Provider HBIPS
NIHSS Score Clarification CSTK-01
NIHSS time STK
NIHSS Timed After Discharge CSTK-01
NIHSS versus mNIHSS CSTK-05
Nimodipine within 24 hours for non-aneurysmal SAH CSTK, CSTK-06
Non Aneurysmal SAH Documentation CSTK-06
Number of cases needed for submission BM
OBS: remains in the ED or transfer to another unit not in the ED STK-OP
One Episode of Care and Thrombolytic Therapy Administration STK
Optimal Medication Management ACHF
Patient Ambulatory At End of Hospital Day 2 STK
Patient Population CSTK
Patient Receiving Continuing Care Plan Only HBIPS-6, HBIPS-7
Patient Referral to Next Level of Care Provider HBIPS
Patients transferred after t-PA STK
Patients with subsequent admissions to the psychiatric unit HBIPS-1, HBIPS-6, HBIPS-7
Please submit all CMS mortality measure questions directly to QnetQuest.org MORT
Please submit all Emergency Department measure questions directly to QnetQuest.org ED, ED-1, ED-2
Please submit all outpatient questions to QnetQuest.org OP
Pneumonia diagnosis: ED/Direct Admint PN
Positive Brain Image CSTK
Positive over negative findings STK-OP
Pradaxa (dabigatran prescribed at discharge) STK-02
Pre-anemia screening BM
PRE-stroke Modified Rankin Indicator question for Cstroke reporting CSTK-02
Pre-transfusion platelet count allowable value BM-04b
Primary Stroke Certification and Transition to Stroke Core Measures STK
Procedure codes for HF outpatients ACHF
Procedure Time Inclusion Terms CSTK-03
Procedures Performed During Hospitalization ACHF
Proof that next level of care provider contact information was transmitted with the Transition of Care Record ACHF
PSC CSTK 01 population CSTK, CSTK-01
PSC Certified Hospitals: Sampling Methodology to Use for CSTK 1 for 2019 STK
Psychiatic Care Setting -Patient Inclusion HBIPS
Question regarding the new STK OP 1 Measure STK-OP
Questions about sampling? ACHF
Rationale for Code Stroke Form as the Priority Data Source STK-4
Reason for Not Administering Antithrombotic Therapy? STK
Reason for extending IV tPA STK-4
Reason for Extending the Initiation of IV Thrombolytic STK, STK-04
Reason for No Anticoagulation Therapy Prescribed at Discharge STK-03
Reason for No VTE Prophylaxis STK, STK-01
Reason for no VTE Prophylaxis - Elevated INR STK, STK-01
Reason for No VTE Prophylaxis - Hemorrhagic Stroke Patient STK-01
Reason For Not Administering Antithrombotic By End of Hospital Day 2 STK
Reason for not giving Nimodipine within 24 hours CSTK
Reason for Not Initiating IV Thrombolytic STK
Reason for Not Initiating IV Thrombolytic-conflicting GWTG instructions STK-04
Reason for Not Prescribing Anticoagulation Therapy at Discharge STK-03
Reason for Not Prescribing Antithrombotic / Anticoagulation at Discharge STK-02
Reason for not prescribing antithrombotic therapy at hospital discharge STK
Recommended ways to obtain mRS CSTK, CSTK-02
Referral to Next Level of Care HBIPS
Referral to Next Level of Care Provider-Trasmittal Question HBIPS-6
Refusal of SCD's STK, STK-01
Rehabilitation Assessment STK
Retirement of STK-7 Dysphagia Screen STK-07
Risk of Violence to Self HBIPS, HBIPS-1
Sampling Methodology for Stroke STK
Sampling Requirements for CSTK CSTK
Sampling Requirements for CSTK CSTK
Sampling when both STK and CSTK are collected by a HCO CSTK
SCIP Inf-9 Urinary catheter removed on Postoperative Day 1 (POD 1 or Postoperative Day 2 (POD 2) with day of surgery being day zero ) SCIP, SCIP Inf-9
SCIP questions related to the April 2010 manual SCIP
SCIP- Neuraxial Anesthesia- Epidural for pain control placed post-op SCIP
Should 'Yes' or 'No' be selected for IV Thrombolytic Initiation? STK
Significance of baseline mRS in calculation of CSTK-10 CSTK-10
Small vessel disease as Evidence of Atherosclerosis STK, STK-06
Statin prescibed the day after discharge STK-06, STK-08
Statin therapy for patients 75yrs and older STK
Statins at Discharge STK-06
STK 10 Assessed for rehabilitation STK-10
STK-10 Assessed for Rehabilitation Services STK-10
STK-1: IV Heparin for VTE Prophylaxis STK, STK-01
STK-4 IV Thrombolytic Therapy STK
STK-5 Antithrombotic - LOVENOX SQ STK
STK-6 "Evidence of Atherosclerosis" STK
STK-6 Reason for Not Prescribing a Statin Medication at Discharge STK
Stroke after admission-arrival to skin puncture CSTK -09 CSTK
Stroke core measure data for PSC hospitals STK
Stroke Diagnosed Mid-Hospital Stay STK-5
Stroke Education Documentation Examples STK-08
Stroke Measure Requirements STK
Stroke Measures STK-7 and STK-9 STK
Stroke Module STK
Stroke that occurs after admission CSTK
Stroke VTE Prophylaxis STK-01
SUB 2 SUB
Support System ACHF
TEDS for VTE Prophylaxis STK, STK-01
The latest update indicates a favorable mRS as 0 1 or 2 post stroke with pre mRS 3 4 or 5 CSTK
Thrombolytic therapy administered at satellite ED prior to hospital arrival STK
thyroid CA PC-01
Time Last Know Well -Stroke STK
Time Last Known Well STK
Time Last Known Well - Conflicting Physician Documentation STK-04
Time Last Known Well is after hospital arrival STK-04
Time NIHSS performed CSTK-01
Time of the teleneurology NIHSS CSTK-01
Transfer between the Psychiatric Unit and Acute Care Unit HBIPS
Transfer in patients that are intubated CSTK-01
Transmission of Continuing Care Plan (CCP) HBIPS, HBIPS-7
Triglyceride >400mg/dL STK
Unable to Calculate LDL Value Due to High Triglycerides STK-06
Use of Sweet-Ease速 and PC-05 (Exclusive Breast Milk Feeding) PC-05
Version 4.4 - Time Last Known Well and Reason Extending IV Thrombolytic STK-04
VTE Prophlyaxis - Abstracting of Allowable Values STK-01
What dosage of Lovenox is suffiecient to meet antithrombotic therapy administered by end of hospital day 2 STK-05
What are the benchmarks for the new Outpatient Stroke Core Measures? STK-OP
What are the recommendations for VTE prophylaxis for stroke patients? STK-01
What constitutes a failed thrombectomy CSTK-11
What dose of enoxaparin is acceptable for use as antithrombotic therapy. STK-2, STK-5
what if Pradaxa (dabigatran is prescribed at discharge?) STK-02
What is the Admission Date? STK
What is the Date and Time Last Known Well? STK-04
What is the Date and Time of Last Well Known? STK-04
What is the purpose of the Missing Branch ('X' Category Assignment for VTE Prophylaxis Date?) STK-01
What should we do when conflicting or multiple times of last known well are documented? STK-04
What terms can be used for Comfort Measures Only? STK
What value should be selected when VTE prophylaxis is administered several days after admission? STK
What version of the Joint Commision manuel will be used starting with January 1, 2010? STK-01, STK-02, STK-03, STK-04, STK-05, STK-06, STK-07, STK-08, STK-09, STK-10, VTE
What would I document as Last Known Well? STK, STK-4
When both SCDs and TEDS are applied on the same day , how are they abstracted? STK
When mutiple ejection fractions (EF are documented in the medical record, which value should we use?) ACHF
When there is a discharge summary and an addendum present in the medical record, which should be used? STK
Which version of the specifications should be used for stroke data collection? STK
Who should perform mRS? CSTK-02
Why are patients that receive t-PA in the ED and then transferred to another hospital excluded from STK-4? STK-04
Why are there not more contraindications to vaginal deliveries? PC
Why aren't more exclusions to elective delivery considered? PC
Why aren't there more newborn conditions listed for not exclusively feeding breast milk? PC-05
Why does a patient on another lipid-lowering medication qualify and fail statin prescribed at discharge? STK-06
Why does a patient treated with another lipid-lowering agent and with LDL < 100 fail the statin measure? STK-06
Why has this indicator has changed to include the word "elective"? STK
Why is a Reason for No VTE Prophylaxis needed with graduated compression stockings (GCS/TEDs?) STK, STK-01
Why is ICD-9-CM Principal Diagnosis Code 436 used for ischemic stroke? STK
Will certified Primary Stroke Centers be required to report the stroke performance measures as core measures? STK
Will Evidence of Atherosclerosis remain a data element? STK-06
Will Evidence of Atherosclerosis remain a STK-6 data element? STK
Will files be rejected if all procedure codes do not have a procedure time? CSTK, CSTK-01, CSTK-03
Will Primary Stroke Certification continue? STK
Will the new AHA recommendation of expasion of the time window for treatment wiht tPA be included in TJC measures/STK4? Other
WIll the new medication Pradaxa be acceptable as an anticoagulant at discharge? STK, STK-03
Written discharge instructions for warfarin therapy VTE-05

Clinical Algorithm Questions

Data Quality Questions

Measure Verification Questions

Measure Verification Questions

Technical Questions

Performance Measurement System Vendor - General Questions

Statistical Questions

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---++ Data Quality Questions
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---++ Measure Verification Questions
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---++ Technical Questions
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---++ Statistical Questions
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