Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

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

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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---++ Statistical Questions
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