Performance Measurement Network

List of All Questions in the FAQ Database

Clinical Specification Questions

Question Related to
Multiple TICI reperfusion grades CSTK-08
Clairfy time to recanalization CSTK, CSTK-07
Nimodipine within 24 hours for non-aneurysmal SAH CSTK, CSTK-06
Recommended ways to obtain mRS CSTK, CSTK-02
doucumentation of ich and hunt hess CSTK-03
Procedure Time Inclusion Terms CSTK-03
Hunt and Hess & ICH Score Documentation CSTK-03
Date/Time of First Pass for CSTK-7 CSTK
Can an addendum be made to a pt's chart that has been d/c - Physician did not place the hunt & hess. CSTK
Version 4.4 - Time Last Known Well and Reason Extending IV Thrombolytic STK-04
Earliest principal procedure time/first pass time CSTK
Initial Date/time of NIHSS teleneurologist CSTK, CSTK-01
NIHSS Score Clarification CSTK-01
Earliest Aneurysm Repair or Surgical Interv Procedure Time CSTK
Follow-up to UserQuestion102705 CSTK
Time of the teleneurology NIHSS CSTK-01
NIHSS Timed After Discharge CSTK-01
Multiple EMRs HBIPS
CSTK Procedure Times CSTK
HBIPS Event Dates Prior to Admission HBIPS
Continuing Care Plan - Reason for Hospitalization HBIPS
Psychiatic Care Setting -Patient Inclusion HBIPS
For patients transfused in Operating Room, how do we respond if there is no "written" order for transfusion. BM-05
In the Operating Room, is "Estimated Blood Loss" for PRBC'S considered transfusion criteria? BM-02
Can estimated blood loss (EBL be used for the data element pre-transfusion hemoglobin/hematocrit.) BM-02
Support System ACHF
Proof that next level of care provider contact information was transmitted with the Transition of Care Record ACHF
Procedures Performed During Hospitalization ACHF
Procedure codes for HF outpatients ACHF
Functional Status at Discharge ACHF
When mutiple ejection fractions (EF are documented in the medical record, which value should we use?) ACHF
Questions about sampling? ACHF
Can we use E/M code 99211? ACHF
EF on admission 15%. Day of discahrge EF 50-55% per ECHO. Do we answer Y for LVSD<40 . ACHF
Optimal Medication Management ACHF
Activity specifics ACHF
activity charting ACHF
Data Element Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD at Discharge has an incomplete sentence ACHF-01
Effect of NUBC's retirement of Point of Origin for Admission or Visit on Core Measures AMI-1, AMI-7, AMI-7a, AMI-8, AMI-8a, AMI-9, PN-3a, PN-5, PN-5c, PN-6a, PN-6b
Does CSTK - 03 include directly admitted transfers (that bypass ED?) CSTK-03
Patient Population CSTK
First Radiographic Image, CSTK 07 STK
Sampling Methodology for Stroke STK
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
Antithrombotic Administration after t-PA STK-05
Documention of Stroke education at discharge, STK-08
Can post discharge documentation of a statin prescription be used in abstraction? STK-06
Need information about the required import file specifications BM
Pre-anemia screening BM
Pre-transfusion platelet count allowable value BM-04b
Number of cases needed for submission BM
Can a patient undergoing Cardiac Surgery who received RBC's, FFP and Platelets be counted for more than one measure? BM
mRS CSTK
CSTK-01 Procedures and Timing 1 calculation CSTK-01
Comprehensive Stroke (CSTK Sub-Populations) CSTK
Sampling Requirements for CSTK CSTK
Will files be rejected if all procedure codes do not have a procedure time? CSTK, CSTK-01, CSTK-03
Who should perform mRS? CSTK-02
Clarification of data elements needed CSTK-05b, CSTK-07
Sampling when both STK and CSTK are collected by a HCO CSTK
Sampling Requirements for CSTK CSTK
CSTK 02, 05, and 06 Measures CSTK-01, CSTK-02, CSTK-05, CSTK-06
Multiple Procedure Times CSTK, CSTK-01
CSTK 4 Denominator Population CSTK-04
Time NIHSS performed CSTK-01
NIHSS versus mNIHSS CSTK-05
Initial Blood Pressure at Hospital Arrival Field Format CSTK-03
ICH score documentation CSTK-03b
Expired after discharge CSTK-02
Positive Brain Image CSTK
CSTK4 documentation time? CSTK-04
First Pass of a Mechanical Reperfusion Device / First Pass Time CSTK, CSTK-05
Transfer in patients that are intubated CSTK-01
Arrival time for transferred patients CSTK-07
Denominator exclusion population ICD-9 CM diagnosis codes CSTK, CSTK-03
can we accept a Drs documentation that it is not a hemorragic transformation CSTK, CSTK-05
Do we need to collect 90 day mRS on pts undergoing CEA/CAS? CSTK
CSTK 3 CSTK, CSTK-03
Failed attempt at thrombectomy CSTK-08
Please submit all Emergency Department measure questions directly to QnetQuest.org ED, ED-1, ED-2
Appropriate Justification for Multiple Antipsychotic Meds at DC - Rationale for Allowable Value 4 HBIPS
Transfer between the Psychiatric Unit and Acute Care Unit HBIPS
Referral to Next Level of Care HBIPS
Data Element- Violence Risk to Self HBIPS
Continuing Care Plan Document Questions HBIPS
Continuing Care Plan-Discharge Medications Indications for Use HBIPS
HBIPS Discharge Status HBIPS
HBIPS-1 Timeframe for Screening Questions HBIPS
HBIPS- Restraint and Seclusion in ED HBIPS-3
Patient Referral to Next Level of Care Provider HBIPS
Next Level of Care Provider Same as Hospital Provider HBIPS
Discharge Medications and Indication for Use HBIPS-6, HBIPS-7
Patient Receiving Continuing Care Plan Only HBIPS-6, HBIPS-7
Referral to Next Level of Care Provider-Trasmittal Question HBIPS-6
Appointment for Follow Up/ Release of Information HBIPS, HBIPS-7
Risk of Violence to Self HBIPS, HBIPS-1
Documentation ofJustification for Multiple Antipsychotic Medications HBIPS
Patients with subsequent admissions to the psychiatric unit HBIPS-1, HBIPS-6, HBIPS-7
Is there benchmark data available for HBIPS Data? HBIPS, HBIPS-1, HBIPS-1b, HBIPS-1c, HBIPS-1d, HBIPS-1e
Transmission of Continuing Care Plan (CCP) HBIPS, HBIPS-7
AMA and Number of Antipsychotic Meds Prescribed at Discharge HBIPS-4, HBIPS-5
Documentation for Stroke Education HF-1
How does new Prevnar recommendation affect Pneumovax administration? IMM
Please submit all CMS mortality measure questions directly to QnetQuest.org MORT
Use of Sweet-Ease速 and PC-05 (Exclusive Breast Milk Feeding) PC-05
Will the new AHA recommendation of expasion of the time window for treatment wiht tPA be included in TJC measures/STK4? Other
Will Evidence of Atherosclerosis remain a STK-6 data element? STK
Please submit all outpatient questions to QnetQuest.org OP
Importance of exclusive breast milk feeding PC
Why aren't there more newborn conditions listed for not exclusively feeding breast milk? PC-05
Mother's choice not to breast feed PC-05
Why aren't more exclusions to elective delivery considered? PC
Why are there not more contraindications to vaginal deliveries? PC
Footling breech code 652.81 as an exclusion for PC-02 PC-02a
Pneumonia diagnosis: ED/Direct Admint PN
SCIP- Neuraxial Anesthesia- Epidural for pain control placed post-op SCIP
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
Small vessel disease as Evidence of Atherosclerosis STK, STK-06
Stroke Measures STK-7 and STK-9 STK
Primary Stroke Certification and Transition to Stroke Core Measures STK
Will Primary Stroke Certification continue? STK
Stroke Measure Requirements STK
STK-6 "Evidence of Atherosclerosis" STK
ICD-9-CM Code 433.10 STK
Admitted for elective carotid intervention STK
Code 433.10 and Transient Ischemic Attack STK
Lovenox 40mg daily - Antithrombotic Therapy Administered by End of Hospital Day Two STK
Documentation for tPA exclusion STK, STK-04
STK-4 IV Thrombolytic Therapy STK
Comparative Data for Stroke Measures STK
Date Last Known Well STK
How to abstact Last Known Well when there is too much information? STK
Time Last Known Well STK
Data Abstraction for "Last Known Well" STK
ABstraction for Date Last Known Well STK
Discharged on Anticoagulation Therapy STK
Are MRI reports an acceptable data source for Evidence of Atherosclerosis? STK-06
Documentation Compliance for IV t-PA STK, STK-04
Unable to Calculate LDL Value Due to High Triglycerides STK-06
Thrombolytic therapy administered at satellite ED prior to hospital arrival STK
Patient Ambulatory At End of Hospital Day 2 STK
Is admission day counted as day 1 for STK-1? STK
One Episode of Care and Thrombolytic Therapy Administration STK
Retirement of STK-7 Dysphagia Screen STK-07
Elective Carotid Intervention STK
Why has this indicator has changed to include the word "elective"? STK
Time Last Know Well -Stroke STK
Time Last Known Well - Conflicting Physician Documentation STK-04
How should Last Known Well be abastracted when there is conflicting documentation in the medical record? STK-04
Stroke Education Documentation Examples STK-08
Stroke VTE Prophylaxis STK-01
Can an addendum be added to the medical record? STK-01
STK-1: IV Heparin for VTE Prophylaxis STK, STK-01
DVT Prophylaxis and Ambulation STK, STK-01
Reason for No VTE Prophylaxis STK, STK-01
Reason For Not Administering Antithrombotic By End of Hospital Day 2 STK
Data abstraction for VTE Prophylaxis when administered prior to admission STK
Is refusal of all IV's a Reason for Not Initiating IV Throbolytic Therapy? STK-04
When both SCDs and TEDS are applied on the same day , how are they abstracted? STK
Triglyceride >400mg/dL STK
Patients transferred after t-PA STK
Documentation for Rehabilitation Assessment STK-10
Elective carotid intervention documentation STK
Abstraction for Clinical Trial (STK ) STK
Is intensive dosing of statin required to meet STK-6? STK
STK-6 Data Entry in CMIP for Q1 2010 STK
Reason for No VTE Prophylaxis - Hemorrhagic Stroke Patient STK-01
Reason for no VTE Prophylaxis - Elevated INR STK, STK-01
Reason for Not Prescribing Anticoagulation Therapy at Discharge STK-03
Reason for Not Administering Antithrombotic Therapy? STK
VTE Prophlyaxis - Abstracting of Allowable Values STK-01
What are the recommendations for VTE prophylaxis for stroke patients? STK-01
Abstraction for Last Known Well STK-04
Discharge Instructions for Activation of Emergency Medical System (EMS (911)) STK-08
Which version of the specifications should be used for stroke data collection? STK
STK 10 Assessed for rehabilitation STK-10
Assessed for Rehabilitation STK
Rehabilitation Assessment STK
Assessed for Rehabaliitation Services STK-10
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
Is the ambulatory patient considered low risk for VTE? STK
Statin prescibed the day after discharge STK-06, STK-08
What value should be selected when VTE prophylaxis is administered several days after admission? STK
Follow-up to UserQuestionId03Stk100628 STK
TEDS for VTE Prophylaxis STK, STK-01
Will Evidence of Atherosclerosis remain a data element? STK-06
Evidence of Atherosclerosis STK
Inter-rater Reliability and Chart Re-asbstraction STK
Admission Date STK-01
Is full medication reconciliation required by PSCs to meet the Medication Education measure component? STK-08
Why is a Reason for No VTE Prophylaxis needed with graduated compression stockings (GCS/TEDs?) STK, STK-01
Reason for not prescribing antithrombotic therapy at hospital discharge STK
Does all medical record documentation need to be dated and timed? STK
Documentation of Stroke Education STK-08
How is Length of Stay (LOS calculated for STK-1?) STK-01
Does the following documentation meet education regarding Risk factors for stroke? STK
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
LDL Measured within first 48 hrs or 30 days prior to hospital arrival STK
Refusal of SCD's STK, STK-01
Statins at Discharge STK-06
Why are patients that receive t-PA in the ED and then transferred to another hospital excluded from STK-4? STK-04
What is the Admission Date? STK
What is the Date and Time of Last Well Known? STK-04
Follow-up to UserQuestionId03Stk100984 STK-04
What is the Date and Time Last Known Well? STK-04
Last Known Well STK-04
Why is ICD-9-CM Principal Diagnosis Code 436 used for ischemic stroke? STK
Reason for No Anticoagulation Therapy Prescribed at Discharge STK-03
Can the following note be used as a Reason for Not Prescribing Anticoagulation Therapy? STK-03
What terms can be used for Comfort Measures Only? STK
WIll the new medication Pradaxa be acceptable as an anticoagulant at discharge? STK, STK-03
What should we do when conflicting or multiple times of last known well are documented? STK-04
Should 'Yes' or 'No' be selected for IV Thrombolytic Initiation? STK
Consideration of PRADAXA as anticoagulation therapy for patients with atrial fibrillation STK-03
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
Pradaxa (dabigatran prescribed at discharge) STK-02
what if Pradaxa (dabigatran is prescribed at discharge?) STK-02
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
Dabigatran (PRADAXA use in Stroke Patients) STK
Is it considered CMO if the palliative care consult was done and the patient refuses palliative care the next day? STK
Reason for Not Initiating IV Thrombolytic STK
Are the following examples acceptable Reasons for Not Prescribing Anticoagulation and Antithrombotic Therapy at Discahrge? STK, STK-02
Does a hold on anticoagulation count as a valid reason for not prescribing at discharge? STK-03
STK-10 Assessed for Rehabilitation Services STK-10
What is the purpose of the Missing Branch ('X' Category Assignment for VTE Prophylaxis Date?) STK-01
If the admitting diagnosis is not stroke, can the case be excluded from STK-4? STK-04
Must the patient refuse both pharmacological and mechanical VTE prophylaxis to count as a reason for no prophylaxis? STK-01
What dosage of Lovenox is suffiecient to meet antithrombotic therapy administered by end of hospital day 2 STK-05
How should we abstract pharmacological VTE prophylaxis when the patient is NPO? STK
Does the reason for not presciribing anticoagulation therapy have to be documented on the dau of discharge? STK-03
Reason for Not Prescribing Antithrombotic / Anticoagulation at Discharge STK-02
Last Known Well STK, STK-04
If tPA is given at an outside hospital by our Critical Transport Team, should we take credit? STK, STK-04
Is this considered a stroke clinical trial patient? STK
Can documentation on a pre-printed stroke order form for VTE Prophylaixs be used as a sufficient reason for no prophylaxis? STK-01
Is Xarelto (Rivaroxaban an acceptable anticoagulant for STK-3?) STK-03
Define who is considered a stroke team for STK 4. STK
Reason for Not Initiating IV Thrombolytic-conflicting GWTG instructions STK-04
Time Last Known Well is after hospital arrival STK-04
Is Xarelto an antithromotic for use in Stroke? Can it be used for antithrombotic med at discharge? STK, STK-02
For Q1 2013 fVTE and Oral Factor Xa inhibitor in Stroke patients. STK-01
Last known well when symptoms resolve then reoccur STK
Reason for Extending the Initiation of IV Thrombolytic STK, STK-04
Statin therapy for patients 75yrs and older STK
Hunt & Hess/ ICH score documentation required by tele neuro radiology prior to transfer STK
Stroke core measure data for PSC hospitals STK
Is heparin 5000U SQ acceptable for antithrombitic administered by end day 2 STK
STK-6 Reason for Not Prescribing a Statin Medication at Discharge STK
What dose of enoxaparin is acceptable for use as antithrombotic therapy. STK-2, STK-5
Last Known Well Version 5.2 STK-4
STK-5 Antithrombotic - LOVENOX SQ STK
Lovenox in reference to STK-2, STK-5, and STK-3 STK-2, STK-3, STK-5
Last Known Well Y/N? STK-4
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
If a physician writes an order for SCDs, is this sufficient to select 'Yes' for VTE Prophylaxis? STK-01, VTE-01
Definition of validated and non-validated screening tool for substance use SUB-01
Graduated Compression Stockings as VTE Prophylaxis for Stroke Patients (STK-1) VTE-01, STK-1
Written discharge instructions for warfarin therapy VTE-05
Dietary Advice "consistent amount" of foods with Vitamin K rather than avoidance should be advised. VTE-05
Jan 2012 Follow-up monitoring VTE-05
Follow-up to UserQuestionId03Vte101043 VTE-05
Will certified Primary Stroke Centers be required to report the stroke performance measures as core measures? STK
Exclusive breast milk feeding definition PC
Are retired Stroke Core Measures still required for comprehensive stroke centers? STK
Stroke Module STK
in 2016, will the vendors still be able to submit STK HCD for STK Certification for our hospitals? 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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