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Paper Patient Medical Records

Valid for Measure Submission

Controlling High Blood Pressure

The percentage of adults 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure was adequately controlled (<140/90 mm Hg) during the measurement year.

CBE ID
0018

Counseling for Women of Childbearing Potential with Epilepsy

All female patients of childbearing potential (12–44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year

CBE ID
1814

CSTK-01: National Institutes of Health Stroke Scale (NIHSS) Score Performed for Ischemic Stroke Patients

Proportion of ischemic stroke patients age 18 years or older for whom an initial NIHSS score is performed prior to any acute recanalization therapy (i.e., intra-venous (IV) thrombolytic (t-PA) therapy, or intra-arterial (IA) thrombolytic (t-PA) therapy, or mechanical endovascular reperfusion (MER) therapy) in patients undergoing recanalization therapy and documented in the medical record, or documented within 12 hours of arrival at the hospital emergency department in patients who do not undergo recanalization therapy.

CBE ID
2864

CSTK-03: Severity Measurement Performed for Subarachnoid Hemorrhage (SAH) and Intracerebral Hemorrhage (ICH) Patients (Overall Rate)

Proportion of SAH and ICH stroke patients age 18 years or older for whom a severity measurement (i.e., Hunt and Hess Scale for SAH patients or ICH Score for ICH patients) is performed prior to surgical intervention (e.g., clipping, coiling, or any surgical intervention) in patients undergoing surgical intervention and documented in the medical record; OR, documented within 6 hours of arrival at the hospital emergency department in patients who do not undergo surgical intervention.

CBE ID
2866

CSTK-06: Nimodipine Treatment Administered

Proportion of subarachnoid hemorrhage (SAH) patients age 18 years and older for whom nimodipine treatment was administered within 24 hours of arrival at this hospital.

This is the sixth measure in a set of measures developed for Joint Commission Comprehensive Stroke Certification. Although it is not required that these measures are reported in conjunction with each other, The Joint Commission develops measures in sets in order to provide as comprehensive a view of quality for a particular clinical topic as possible.

CBE ID
2863

CVD Risk Assessment Measure- Proportion of Pregnant/postpartum patients who receive CVD Risk Assessment with a standardized tool

The CVD Risk Assessment Measure represents the proportion of pregnant and postpartum individuals assessed for CVD risk using a standardized tool at the clinic and facility levels of health care service delivery. The CVD risk assessment identifies pregnant and postpartum individuals without an existing CVD diagnosis who may have cardiovascular disease (CVD) or are at an increased risk of developing CVD, thus necessitating further evaluation. 

 

CBE ID
4715

Depression Assessment with PHQ-9/ PHQ-9M

The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with a diagnosis of major depression or dysthymia who have a completed PHQ-9 or PHQ-9M tool during a four month measurement period.

CBE ID
0712

Depression Remission at Six Months

The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who reach remission six months (+/- 60 days) after an index visit.

CBE ID
0711