Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

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

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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