Paper Patient Medical Records

Use of systemic corticosteroids in pediatric asthma patients (age 2 through 17 years) admitted for inpatient treatment of asthma. This measure is a part of a set of three nationally implemented measures that address children’s asthma care (CAC-1: Relievers for Inpatient Asthma, CAC-3: Home Management Plan of Care (HMPC) Document Given to Parent/Caregiver) that are used in The Joint Commission’s accreditation process.

Percentage of patients admitted to a hospital with a primary diagnosis of an acute myocardial infarction or chronic stable angina or who during hospitalization have undergone coronary artery bypass (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery (CVS), or cardiac transplantation who are referred to an early outpatient cardiac rehabilitation/secondary prevention program.

Cardiac surgery patients with controlled postoperative blood glucose (less than or equal to 180 mg/dL) in the timeframe of 18 to 24 hours after Anesthesia End Time.

Percentage of adults 65 years and older who had a medication review during the measurement year. A medication review is a review of all a patient’s medications, including prescription medications, over-the-counter (OTC) medications and herbal or supplemental therapies by a prescribing practitioner or clinical pharmacist.

Standardized infection ratio (SIR) and Adjusted Ranking Metric (ARM) of hospital-onset CDI Laboratory-identified events (LabID events) among all inpatients in the facility, excluding well-baby nurseries and neonatal intensive care units (NICUs).

Percentage of intensive care patients with central lines for whom all
elements of the central line bundle are documented and in place.
The central line bundle elements include:
•Hand hygiene
•Maximal barrier precautions upon insertion
•Chlorhexidine skin antisepsis
•Optimal catheter site selection, with avoidance of the femoral vein for central venous access in patients 18 years and older
•Daily review of line necessity with prompt removal of unnecessary lines

The percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria:
-Women 21–64 years of age who had cervical cytology performed within the last 3 years.
-Women 30–64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last 5 years.
-Women 30–64 years of age who had cervical cytology/high-risk human papillomavirus (hrHPV) cotesting within the last 5 years.

Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DtaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine.

The percentage of female adolescents 18 years of age who had a chlamydia screening test with proper follow-up.

Percentage of patients aged 18 years through 80 years with AJCC Stage III colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy or have previously received adjuvant chemotherapy within the 12-month reporting period