Release Notes:
Measure Information Form
Version 2012B
Measure Information Form
Measure Set: Hospital Based Inpatient Psychiatric Services (HBIPS)
Set Measure ID: HBIPS-2b
Performance Measure Name: Physical Restraint- Children (1 through 12 years)
Description:
Rationale:
Type of Measure:
Improvement Noted As:
Numerator Statement:
Included Populations:
Excluded Populations:
Data Elements:
Denominator Statement:
Included Populations:
Excluded Populations:
Data Elements:
Continuous Variable Statement:
Included Populations:
Excluded Populations:
Data Elements:
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- ABG Done
- ACEI Prescribed at Discharge
- ACEI Prescribed for LVSD in the Outpatient Setting
- ACEI or ARB for LVSD
- ACEI or ARB for LVSD
- ARB Prescribed at Discharge
- ARB Prescribed for LVSD in the Outpatient Setting
- Active Clinical Staff
- Active Labor
- Activity Recommendations Document
- Acute Myocardial Infarction
- Admission Date
- Admission Date-Stroke
- Admission From Home
- Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strengths completed
- Admission Screening- Adolescent (13 through 17 years)
- Admission Screening- Adult (18 through 64 years)
- Admission Screening- Children (1 through 12 years)
- Admission Screening- Older Adult (≥65 years)
- Admission Screening- Overall Rate
- Admission Time
- Admission Type
- Admission to NICU
- Admit Decision Time to ED Departure Time for Admitted Patients
- Admitted for Elective Carotid Endarterectomy
- Adult Smoking Cessation Advice/Counseling
- Adult Smoking Cessation Advice/Counseling
- Adult Smoking Cessation Advice/Counseling
- Adult Smoking Counseling
- Adult Smoking Counseling-Stroke
- Adult Smoking History
- Adult Smoking History-Stroke
- Advance Directives
- Advanced Certification Heart Failure
- Age
- Age 18 or Greater
- Alcohol & Drug Use: Assessing Status After Discharge
- Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge
- Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge
- Alcohol & Other Drug Use Disorder Treatment at Discharge
- Alcohol Use Brief Intervention
- Alcohol Use Brief Intervention Provided or Offered
- Alcohol Use Brief Intervention Provided or Offered
- Alcohol Use Screening
- Alcohol Use Status
- Alcohol or Drug Disorder
- Alcohol or Drug Use Status Post-Discharge (Not used in measure calculation)
- Aldosterone Receptor Antagonist Prescribed for LVSD in the Outpatient Setting
- Anesthesia Start Date
- Another Suspected Source of Infection
- Antenatal Steroid Administered
- Antenatal Steroids
- Antibiotic Administration Date
- Antibiotic Administration Route
- Antibiotic Administration Time
- Antibiotic Allergy
- Antibiotic Name
- Antibiotic Received
- Antibiotic Selection
- Antibiotic Timing
- Antibiotic Timing (Median)
- Antithrombotic Therapy Administered by End of Hospital Day Two
- Antithrombotic Therapy By End of Hospital Day Two
- Antithrombotic Therapy Prescribed at Discharge
- Appropriate Justification for Multiple Antipsychotic Medications
- Arrival Date
- Arrival Date
- Arrival Date-Stroke
- Arrival Time
- Arrival Time-Stroke
- Aspirin Prescribed at Discharge
- Aspirin Prescribed at Discharge
- Aspirin Received Within 24 Hours Before or After Hospital Arrival
- Aspirin at Arrival
- Aspirin at Arrival
- Assessed for Rehabilitation
- Assessed for Rehabilitation Services
- Assessment - Bone Health Risk
- Assessment - Fatigue
- Assessment - Lymphedema
- Assessment - Menopausal Symptoms
- Assessment - Neuropathy
- Assessment - Pain
- Assessment - Psychosocial Distress
- Assessment - Sleep
- Assessment for Chemotherapy Induced Nausea and Vomiting
- Assessment for Chemotherapy Induced Nausea and Vomiting
- Assessment for Distress
- Assessment for Fatigue
- Assessment for Sleep-Wake Disturbance
- Atrial Fibrillation
- Background Check
- Beta-Blocker Current Medication
- Beta-Blocker During Pregnancy
- Beta-Blocker Perioperative
- Beta-Blocker Prescribed at Discharge
- Beta-Blocker Prescribed at Discharge
- Beta-Blocker Received Within 24 Hours After Hospital Arrival
- Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate) for LVSD Prescribed at Discharge
- Beta-Blocker at Arrival
- Birth Weight
- Birthdate
- Birthdate
- Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD in the Outpatient Setting
- Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD at Discharge
- Blood Administration Documentation
- Blood Administration Location
- Blood Bank Records
- Blood Culture Collected
- Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival
- Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital
- Blood ID Number
- Blood Type Testing Ordered
- Bone Mineral Density Test Performed in the 12 Months Prior to the Fracture
- Breast Cancer Care
- Breast Cancer Stage
- Breast Cancer Survivorship
- Breast Imaging
- Brief Intervention
- CMS Certification Number
- CMS Risk-Adjusted 30-Day Mortality
- CPT® Code
- CSF Prescribed
- Cardiac Arrest
- Cardiac Arrest Date
- Cardiac Arrest Event Number
- Cardiac Arrest Time
- Cardiac Resynchronization Therapy
- Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood Glucose
- Care Transition Record Given to Patient/Caregiver
- Care Transition Record Present
- Care Transition Record Transmitted
- Care Transition Record-Condition or Functional Status at Discharge
- Care Transition Record-Designated Patient Caregiver or Social Support
- Care Transition Record-Discharge Medications
- Care Transition Record-Follow-Up Treatment and Services Needed
- Care Transition Record-Location, Date, and Time of Post-Discharge Appointment
- Care Transition Record-Next Level of Care Provider Contact Information
- Care Transition Record-Procedures Performed During Hospitalization
- Care Transition Record-Reason for Hospitalization
- Care Transition Record-Treatments/Services Provided
- Case Identifier
- Central Line-Associated Bloodstream Infection Rate
- Cesarean Section
- Cesarean Section - 15 through 19 years
- Cesarean Section - 20 through 24 years
- Cesarean Section - 25 through 29 years
- Cesarean Section - 30 through 34 years
- Cesarean Section - 35 through 39 years
- Cesarean Section - 40 through 44 years
- Cesarean Section - 45 through 64 years
- Cesarean Section - 8 through 14 years
- Cesarean Section - Overall Rate
- Chemotherapy Cycle Number
- Chest X-Ray
- Children’s Asthma Care
- Cholesterol Reducing Therapy Prescribed at Discharge
- Cholesterol Reducing Therapy Prior To Hospitalization
- Clinical Indication for Plasma
- Clinical Indication for Platelets
- Clinical Indication for Prophylactic Platelets
- Clinical Indication for RBCs
- Clinical Staff
- Clinical Trial
- Clinical Trial - Osteo
- Code Status Order
- Code Status Order Date
- Code Status Order Time
- Cognitive Impairment
- Colony Stimulation Factors (CSF) Prescribed
- Colorectal Surgery Patients with Immediate Postoperative Normothermia
- Comatose
- Comfort Measures Only
- Comfort Measures Only
- Comfort Measures Only-Stroke
- Competency
- Completeness of Personnel File
- Compromised
- Congenital Anomalies
- Consent Addressed Transfusion Benefits
- Consent Addressed Transfusion Risks
- Continuing Assessment
- Continuing Assessment - Distress
- Continuing Assessment - Fatigue
- Continuing Assessment - Overall Rate
- Continuing Assessment - Sleep-Wake Disturbance
- Continuing Care Plan-Discharge Medications
- Continuing Care Plan-Next Level of Care
- Continuing Care Plan-Principal Discharge Diagnosis
- Continuing Care Plan-Reason for Hospitalization
- Contraindication to Systemic Corticosteroids
- Contraindication to Aspirin at Discharge
- Contraindication to Aspirin on Arrival
- Contraindication to Beta-Blocker - Perioperative
- Contraindication to Beta-Blocker at Discharge
- Contraindication to Beta-Blocker on Arrival
- Contraindication to Both ACEI and ARB at Discharge
- Contraindication to Relievers
- Contraindication to VTE Prophylaxis
- Coordination of Care
- DVT Prophylaxis Initiated by End of Hospital Day 2
- DXA Scan Ordered or Performed Prior to Discharge
- Data Source
- Date
- Date IV Thrombolytic Therapy Administered At This Hospital
- Date Last Known Well
- Date Therapeutic Hypothermia Ended
- Date Therapeutic Hypothermia Initiated
- Date Therapeutic Hypothermia Ordered
- Date of Infection
- Death Among Surgical Inpatients with Treatable Serious Complications
- Diagnostic Uncertainty
- Discharge Date
- Discharge Date-SCA
- Discharge Disposition
- Discharge Instructions
- Discharge Instructions Address Activity
- Discharge Instructions Address Diet
- Discharge Instructions Address Follow-up
- Discharge Instructions Address Medications
- Discharge Instructions Address Symptoms Worsening
- Discharge Instructions Address Weight Monitoring
- Discharge Instructions – Emergency Department
- Discharge Status
- Discharge Status
- Discharge Status-Stroke
- Discharge Time
- Discharged Home From The ED
- Discharged on Antithrombotic Therapy
- Discharged on Cholesterol Reducing Medication
- Discussion of Advance Directives
- Disease Specific Instrument
- Distress
- Distress Improvement
- Do Not Return - Clinical
- Do Not Return - Clinical
- Do Not Return - Professional
- Do Not Return - Professional
- Do Not Return Occurrence Identifier
- Dysphagia Screen
- Dysphagia Screening
- E/M Code
- ED Patient
- Education Addresses Activation of Emergency Medical System
- Education Addresses Follow-up After Discharge
- Education Addresses Medication Prescribed
- Education Addresses Risk Factors for Stroke
- Education Addresses Warning Signs and Symptoms of Stroke
- Education on Community Resources
- Education on Diet
- Education on Exercise
- Education on Late Effects
- Education on Lymphedema
- Education on Neutropenia Precautions
- Education on Recurrence
- Elective Delivery
- Elective Surgery
- Emergency Department
- Emergency Order Date
- Emergency Order Time
- Emergency Transfusion
- Emergency Transfusion Date
- Emergency Transfusion Time
- Emetogenic Agents
- Endotracheal Intubation Confirmation Date
- Endotracheal Intubation Confirmation Time
- Endotracheal Intubation Date
- Endotracheal Intubation Time
- Endotracheal Tube Insertion
- Evaluation of LVS Function
- Event Date
- Event Type
- Exclusive Breast Milk Feeding
- Exclusive Breast Milk Feeding
- Exercise Program
- FDA-approved Pharmacotherapy for Treatment of Osteoporosis
- Falls with Injury
- Fatigue Improvement
- Fatigue Level Begin
- Fatigue Level End
- Fibrinolytic Administration
- Fibrinolytic Administration Date
- Fibrinolytic Administration Time
- Fibrinolytic Therapy Received Within 30 Minutes
- Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
- Final Treatment Date
- First Chemotherapy Date
- First Defibrillation Shock Date
- First Defibrillation Shock Time
- First In-Hospital LDL-Cholesterol Qualitative Description
- First In-Hospital LDL-Cholesterol Value
- First Name
- First PCI Date
- First PCI Time
- Follow Up Care
- Follow Up Care - Breast Imaging
- Follow Up Care - Composite Rate
- Follow Up Care - Coordination of Care
- Follow Up Care - LVEF Assessment
- Follow Up Care - Pelvic Exam
- Follow-up Contact
- Follow-up Contact Date
- Gestational Age
- Glucose POD 1
- Glucose POD 2
- Goal Attainment
- Goal Setting
- Goals Collaborative
- Health Care Organization Identifier
- Health Care Staffing Services
- Health Care-Associated Bloodstream Infections in Newborns
- Health Status
- Healthcare Associated PN
- Heart Failure
- Hispanic Ethnicity
- Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver
- Home Management Plan of Care Document Addresses Arrangements for Follow-up Care
- Home Management Plan of Care Document Addresses Environmental Control and Control of Other Triggers
- Home Management Plan of Care Document Addresses Methods and Timing of Rescue Actions
- Home Management Plan of Care Document Addresses Use of Controllers
- Home Management Plan of Care Document Addresses Use of Relievers
- Home Management Plan of Care Document Given to Patient/Caregiver
- Home Management Plan of Care Document Present
- Hospital Based Inpatient Psychiatric Services
- Hospital Outpatient ACEI or ARB Prescribed for LVSD
- Hospital Outpatient Activity Recommendations
- Hospital Outpatient Aldosterone Receptor Antagonists Prescribed for LVSD
- Hospital Outpatient Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate) Prescribed for LVSD
- Hospital Outpatient Cardiac Resynchronization Therapy (CRT, CRT with pacing CRT-P, CRT with defribrillator CRT-D)
- Hospital Outpatient Department
- Hospital Outpatient Discussion of Advance Directives
- Hospital Outpatient ICD Counseling for LVSD
- Hosptial Outpatient Assessment of Functional Status for Heart Failure
- Hours Worked
- Hours of physical restraint use
- Hours of seclusion use
- ICD Counseling
- ICD Population Size
- ICD-9-CM Diagnosis Code
- ICD-9-CM Other Diagnosis Codes
- ICD-9-CM Other Procedure Codes
- ICD-9-CM Other Procedure Dates
- ICD-9-CM Principal Diagnosis Code
- ICD-9-CM Principal Procedure Code
- ICD-9-CM Principal Procedure Date
- ICU Transfer or Admission Within First 24 Hours
- ICU VTE Prophylaxis
- IV Thrombolytic Therapy Administered
- Identified Pathogen
- Immunization
- Implanted Device
- In-Hospital LDL-Cholesterol Test
- Incidence of Potentially Preventable Hospital-Acquired VTE
- Infection Prior to Anesthesia
- Influenza Vaccination
- Influenza Vaccination Status
- Information Addressed Risks, Benefits and Alternatives to Transfusion
- Initial Antibiotic Received Within 4 Hours of Hospital Arrival
- Initial Antibiotic Received Within 6 Hours of Hospital Arrival (NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE)
- Initial Antibiotic Received Within 8 Hours of Hospital Arrival - RETIRED
- Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients
- Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients – Intensive Care Unit (ICU) Patients
- Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients – Non ICU Patients
- Initial Blood Culture Collection Date
- Initial Blood Culture Collection Time
- Initial ECG Interpretation
- Initial Patient Population Size – Medicare Only
- Initial Patient Population Size – Non-Medicare Only
- Initial Rhythm
- Initiation of Therapeutic Hypothermia
- Inpatient Mortality
- Inpatient Neonatal Mortality
- Instructions on Hand Washing
- Instructions to Contact Provider
- Intervention for Bone Health Risk
- Intervention for Distress
- Intervention for Distress
- Intervention for Fatigue
- Intervention for Fatigue
- Intervention for Lymphedema
- Intervention for Menopausal Symptoms
- Intervention for Neuropathy
- Intervention for Pain
- Intervention for Psychosocial Distress
- Intervention for Sleep
- Intervention for Sleep -Wake Disturbance
- Intervention for Sleep-Wake Disturbance
- Job Appropriate Credentials
- Joint Revision
- LDL ≥ 100 mg/dL
- LDL Cholesterol Assessment (Optional Test Measure)
- LVEF Assessment
- LVF Assessment
- LVSD
- LVSD < 40%
- LVSD of < 35%
- Laboratory Investigation for Secondary Causes of Osteoporosis
- Laboratory Testing Performed in the Prior 12 Months
- Laboratory Tests Ordered or Performed Prior to Discharge
- Laparoscope
- Last Name
- Left Bundle Branch Block (LBBB) on ECG
- Left Ventricular Assist, Device Biventricular Assist Device
- Lipid-Lowering Agent Prescribed at Discharge
- Lipid-Lowering Therapy at Discharge (Optional Test Measure)
- Maintenance of Thermoregulation in Therapeutic Hypothermia
- Measure Category Assignment
- Measure Category Assignment
- Measure Set
- Measurement Value
- Median Time from ED Arrival to ED Departure for Admitted ED Patients
- Median Time to ECG
- Median Time to Fibrinolysis
- Median Time to Fibrinolysis
- Median Time to Primary PCI
- Median Time to Transfer to Another Facility for Coronary Intervention
- Methods of Intubation Confirmation
- Minutes of Physical Restraint
- Minutes of Seclusion
- Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Adolescent (13 through 17 years)
- Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Adult (18 through 64 years)
- Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Children (1 through 12 years)
- Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Older Adult (≥ 65 years)
- Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Overall Rate
- Multiple Antipsychotic Medications at Discharge- Adolescent (13 through 17 years)
- Multiple Antipsychotic Medications at Discharge- Adult (18 through 64 years)
- Multiple Antipsychotic Medications at Discharge- Children (1 through 12 years)
- Multiple Antipsychotic Medications at Discharge- Older Adult (≥ 65 years)
- Multiple Antipsychotic Medications at Discharge- Overall Rate
- Multiple Births
- Myelosuppressive Chemotherapy
- NPO (Nothing by Mouth) For Entire Hospital Stay
- NYHA Class
- National Provider Identifier
- Neuraxial Anesthesia
- Neutropenia Risk Cycle
- Newborn Admission Source
- Non-Primary PCI
- Number of Antipsychotic Medications Prescribed at Discharge
- Number of Cases with UTD Allowable Values
- Number of Rejected Cases
- Nursing Care Hours per Patient Day
- Nursing-Sensitive Care
- On FDA-approved Pharmacotherapy for Treatment of Osteoporosis Prior to Fracture
- Optimal Medication Management
- Oral Administration of Vitamin D
- Oral Antibiotics
- Osteoporosis
- Other Fracture Risk Assessment Method Ordered or Performed Prior to Discharge
- Other Surgeries
- Outpatient Encounter Date
- Parity
- Patient Ambulatory at End of Hospital Day Two
- Patient Blood Management
- Patient Discharged on Anticoagulation Therapy
- Patient Falls
- Patient HIC#
- Patient ID Verification
- Patient Identifier
- Patient Location
- Patient Referral to Next Level of Care Provider
- Patient Strengths
- Patients discharged on multiple antipsychotic medications
- Patients discharged on multiple antipsychotic medications with appropriate justification
- Patients with Atrial Fibrillation Receiving Anticoagulation Therapy
- Payment Source
- Pelvic Exam
- Performance Measure Identifier
- Performance Measurement System Identifier
- Perinatal Care
- Perioperative Death
- Personnel File Record Identifier
- Physical Restraint- Adolescent (13 through 17 years)
- Physical Restraint- Adult (18 through 64 years)
- Physical Restraint- Children (1 through 12 years)
- Physical Restraint- Older Adult (≥ 65 years)
- Physical Restraint- Overall Rate
- Physician 1
- Physician 2
- Plan for LDL-Cholesterol Test
- Plasma ID
- Plasma Event Total Doses
- Plasma Transfusion Indication
- Platelet ID
- Platelet Event Total Doses
- Platelet Transfusion Indication
- Pneumococcal Vaccination
- Pneumococcal Vaccination Status
- Pneumonia
- Pneumonia Diagnosis: ED/Direct Admit
- Point of Origin for Admission or Visit
- Point of Origin for Admission or Visit
- Point of Origin for Admission or Visit-Stroke
- Post Discharge Continuing Care Plan Transmitted - Adolescent (13 through 17 years)
- Post Discharge Continuing Care Plan Transmitted - Adult (18 through 64 years)
- Post Discharge Continuing Care Plan Transmitted - Children (1 through 12 years)
- Post Discharge Continuing Care Plan Transmitted - Older Adult (≥65 years)
- Post Discharge Continuing Care Plan Transmitted- Overall Rate
- Post Discharge Continuing Care Plan- Adolescent (13 through 17 years)
- Post Discharge Continuing Care Plan- Adult (18 through 64 years)
- Post Discharge Continuing Care Plan- Children (1 through 12 years)
- Post Discharge Continuing Care Plan- Older Adult (≥ 65 years)
- Post Discharge Continuing Care Plan- Overall Rate
- Post discharge continuing care plan created
- Post discharge continuing care plan transmitted to next level of care provider upon discharge
- Post-Discharge Appointment Scheduled Within 7 Days
- Post-Discharge Appointment for Heart Failure Patients
- Post-Discharge Evaluation Conducted Within 72 Hours
- Post-Discharge Evaluation for Heart Failure Patients
- Post-Treatment Education
- Post-Treatment Education - Community Resources
- Post-Treatment Education - Composite Rate
- Post-Treatment Education - Diet
- Post-Treatment Education - Exercise
- Post-Treatment Education - Late Effects
- Post-Treatment Education - Lymphedema
- Post-Treatment Education - Recurrence
- Postal Code
- Postoperative Infections
- Practice Environmental Scale-Nursing Work Index
- Pre-Arrival LDL-Cholesterol Qualitative Description
- Pre-Arrival LDL-Cholesterol Test
- Pre-Arrival LDL-Cholesterol Value
- Pre-Arrival Lipid-Lowering Agent
- Pre-Treatment Assessment
- Pre-Treatment Assessment - Distress
- Pre-Treatment Assessment - Fatigue
- Pre-Treatment Assessment - Overall Rate
- Pre-Treatment Assessment - Sleep-Wake Disturbance
- Pre-transfusion Hematocrit Result
- Pre-transfusion Hemoglobin
- Pre-transfusion Hemoglobin
- Pre-transfusion Hemoglobin Result
- Pre-transfusion INR Result
- Pre-transfusion Laboratory Testing
- Pre-transfusion PT/INR
- Pre-transfusion Platelet Count
- Pre-transfusion Platelet Count Result
- Pre-transfusion Platelet Testing
- Pre-transfusion Platelet Testing
- Preadmission Warfarin
- Predicted Value
- Pregnancy and Related Conditions
- Preoperative Anemia Screening
- Preoperative Anemia Screening
- Preoperative Anemia Screening Hematocrit Result
- Preoperative Anemia Screening Hemoglobin Result
- Preoperative Anemia Screening Result Date
- Preoperative Blood Type Testing
- Preoperative Blood Type Testing and Antibody Screening
- Preoperative Hair Removal
- Prescription for Alcohol or Drug Disorder Medication
- Prescription for Tobacco Cessation Medication
- Pressure Ulcer Prevalence
- Primary PCI Received Within 90 Minutes of Hospital Arrival
- Prior Diagnosis of Osteoporosis
- Prior Uterine Surgery
- Progress Toward Goals
- Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
- Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - CABG
- Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Colon Surgery
- Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Hip Arthroplasty
- Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Hysterectomy
- Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Knee Arthroplasty
- Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Other Cardiac Surgery
- Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Overall Rate
- Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Vascular Surgery
- Prophylactic Antibiotic Selection for Surgical Patients
- Prophylactic Antibiotic Selection for Surgical Patients - CABG
- Prophylactic Antibiotic Selection for Surgical Patients - Colon Surgery
- Prophylactic Antibiotic Selection for Surgical Patients - Hip Arthroplasty
- Prophylactic Antibiotic Selection for Surgical Patients - Hysterectomy
- Prophylactic Antibiotic Selection for Surgical Patients - Knee Arthroplasty
- Prophylactic Antibiotic Selection for Surgical Patients - Other Cardiac Surgery
- Prophylactic Antibiotic Selection for Surgical Patients - Overall Rate
- Prophylactic Antibiotic Selection for Surgical Patients - Vascular Surgery
- Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
- Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Colon Surgery
- Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Hip Arthroplasty
- Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Knee Arthroplasty
- Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Overall Rate
- Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Vascular Surgery
- Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time – Hysterectomy
- Prophylactic Antibiotics Discontinued Within 48 Hours After Surgery End Time - Other Cardiac Surgery
- Prophylactic Antibiotics Discontinued Within 48 Hours After Surgery End Time – CABG
- Provider ID
- Provider ID
- Pseudomonas Risk
- Psychiatric Care Setting
- Psychiatric Inpatient Days - Medicare Only
- Psychiatric Inpatient Days-Non-Medicare Only
- Psychological Trauma History
- Psychosocial Distress Level Begin
- Psychosocial Distress Level End
- Pulse Oximetry Done
- RBC Event Total Doses
- RBC ID
- RBC Transfusion Indication
- RBC Unit Exclusions
- Race
- Re-Assessment for Distress
- Re-Assessment for Fatigue
- Re-Assessment for Sleep-Wake Disturbance
- Reason for Delay in Fibrinolytic Therapy
- Reason for Delay in PCI
- Reason for Early Discontinuation of Therapeutic Hypothermia
- Reason for No ACEI and No ARB prescribed for LVSD in Outpatient Setting
- Reason for No Activity Recommendations in the Outpatient Setting
- Reason for No Aldosterone Receptor Antagonist Prescribed for LVSD in the Outpatient Setting
- Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD at Discharge
- Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Prescribed for LVSD in the Outpatient Setting
- Reason for No Cardiac Resynchronization Therapy in the Outpatient Setting
- Reason for No DXA Scan
- Reason for No FDA-approved Pharmacotherapy for Treatment of Osteoporosis
- Reason for No ICD Counseling in the Outpatient Setting
- Reason for No LDL-Cholesterol Testing
- Reason for No Lipid-Lowering Therapy
- Reason for No Post-Discharge Appointment Within 7 Days
- Reason for No Preoperative Anemia Screening
- Reason for No Tobacco Cessation Medication During the Hospital Stay
- Reason for No Tobacco Cessation Medication at Discharge
- Reason for Not Administering Antenatal Steroid
- Reason for Not Administering Therapeutic Hypothermia
- Reason for Not Exclusively Feeding Breast Milk
- Reason for Not Prescribing CSF
- Reason for Not Recommending Exercise
- Reason for Transfer
- Reason for Transfer Out Prior to Therapeutic Hypothermia
- Referral for Addictions Treatment
- Referral for Outpatient Tobacco Cessation Counseling
- Relievers Administered
- Relievers for Inpatient Asthma
- Relievers for Inpatient Asthma (age 13 through 17 years)
- Relievers for Inpatient Asthma (age 2 through 17 years) – Overall Rate
- Relievers for Inpatient Asthma (age 2 through 4 years)
- Relievers for Inpatient Asthma (age 5 through 12 years)
- Report Period
- Restraint Prevalence (vest and limb)
- Return of Spontaneous Circulation
- Return of Spontaneous Circulation
- Risk Assessment/Treatment After Fracture
- Risk Factors for Drug-Resistant Pneumococcus
- Sample
- Sample Size – Medicare Only
- Sample Size – Non-Medicare Only
- Sampling Frequency
- Seclusion- Adolescent (13 through 17 years)
- Seclusion- Adult (18 through 64 years)
- Seclusion- Children (1 through 12 years)
- Seclusion- Older Adult (≥ 65 years)
- Seclusion- Overall Rate
- Sex
- Skill Mix
- Sleep-Wake Disturbance
- Smoking Cessation / Advice / Counseling
- Smoking Cessation Counseling for Acute Myocardial Infarction
- Smoking Cessation Counseling for Heart Failure
- Smoking Cessation Counseling for Pneumonia
- Specified Laboratory Tests
- Spontaneous Rupture of Membranes
- Stroke Education
- Stroke Performance Measures
- Substance Use
- Substance Use Measures
- Sudden Cardiac Arrest
- Surgery End Date
- Surgery End Time
- Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery
- Surgery Patients on Beta-Blocker Therapy Prior to Admission Who Received a Beta-Blocker During the Perioperative Period
- Surgery Patients with Appropriate Hair Removal
- Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
- Surgery Scheduled Timeframe
- Surgery Start Date
- Surgical Care Improvement Project
- Surgical Incision Time
- Surgical Procedure
- Survivorship Visits
- Symptom - Bone Health Risk
- Symptom - Fatigue
- Symptom - Lymphedema
- Symptom - Menopausal
- Symptom - Neuropathy
- Symptom - Pain
- Symptom - Psychosocial Distress
- Symptom - Sleep
- Symptom Assessment
- Symptom Assessment - Bone Health Risk
- Symptom Assessment - Composite Rate
- Symptom Assessment - Fatigue
- Symptom Assessment - Lymphedema
- Symptom Assessment - Menopausal
- Symptom Assessment - Neuropathy
- Symptom Assessment - Pain
- Symptom Assessment - Psychosocial Distress
- Symptom Assessment - Sleep
- Symptom Intervention
- Symptom Intervention - Bone Health Risk
- Symptom Intervention - Composite Rate
- Symptom Intervention - Fatigue
- Symptom Intervention - Lymphedema
- Symptom Intervention - Menopausal
- Symptom Intervention - Neuropathy
- Symptom Intervention - Pain
- Symptom Intervention - Psychosocial Distress
- Symptom Intervention - Sleep
- Systemic Corticosteroids Administered
- Systemic Corticosteroids for Inpatient Asthma
- Systemic Corticosteroids for Inpatient Asthma (age 13 through 17 years)
- Systemic Corticosteroids for Inpatient Asthma (age 2 through 17 years) – Overall Rate
- Systemic Corticosteroids for Inpatient Asthma (age 2 through 4 years)
- Systemic Corticosteroids for Inpatient Asthma (age 5 through 12 years)
- Temperature Value
- Therapeutic Hypothermia Initiated
- Thermoregulation Maintained
- Third or Fourth Degree Laceration
- Thrombolytic Therapy Administered
- Time IV Thrombolytic Therapy Administered at This Hospital
- Time Last Known Well
- Time Therapeutic Hypothermia Ended
- Time Therapeutic Hypothermia Initiated
- Time Therapeutic Hypothermia Ordered
- Timeliness of First Defibrillation Attempt
- Timely Confirmation of Correct Endotracheal Tube
- Tobacco Treatment Measures
- Tobacco Use Screening
- Tobacco Use Status
- Tobacco Use Status Post-Discharge (Not used in measure calculation)
- Tobacco Use Treatment
- Tobacco Use Treatment
- Tobacco Use Treatment FDA-Approved Cessation Medication
- Tobacco Use Treatment Practical Counseling
- Tobacco Use Treatment Provided or Offered
- Tobacco Use Treatment Provided or Offered
- Tobacco Use Treatment Provided or Offered at Discharge
- Tobacco Use Treatment Provided or Offered at Discharge
- Tobacco Use Treatment at Discharge
- Tobacco Use: Assessing Status after Discharge
- Total Leave Days - Medicare Only
- Total Leave Days-Non-Medicare Only
- Transfer From Another ED
- Transferred From or Expired in Emergency Department
- Transfusion Consent
- Transfusion Consent
- Transfusion Order
- Transfusion Start Date
- Transfusion Start Time
- Transfusion Type
- Treatment - Bilateral Mastectomy
- Treatment - Bone Health Risk
- Treatment - Breast Conserving
- Treatment - Menopause Inducer
- Treatment - Neuropathy Causing
- Treatment - Surgery or Radiation
- Treatment - Tamoxifen
- Treatment - Trastuzumab
- Underlying Cause of Osteoporosis
- Unique Blinded Case Identifier
- Unique Blinded Health Care Organization Identifier
- Urinary Catheter-Associated Urinary Tract Infection Rate
- VBAC
- VTE Discharge Instructions
- VTE Patients Receiving UFH with Dosages/Platelet Count Monitoring by Protocol or Nomogram
- VTE Patients with Anticoagulation Overlap Therapy
- VTE Prophylaxis
- VTE Prophylaxis
- VTE Timely
- Vancomycin
- Vendor Tracking Identifier
- Venous Thromboembolism
- Venous Thromboembolism (VTE) Prophylaxis
- Ventilator-Associated Pneumonia Rate
- Violence Risk to Others
- Violence Risk to Self
- Vital Sign Monitoring
- Voluntary Turnover
- Written Discharge Instructions
- deleted from ACHF - Care Transition Record-Condition or Functional Status at Discharge
Risk Adjustment: Yes.
Data Accuracy:
Measure Analysis Suggestions:
Sampling: Yes.
Data Reported As: .
Selected References:
Measure Algorithm: