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Paper Patient Medical Records

Valid for Measure Submission

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

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

Depression Remission at Twelve Months

  • Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. 
    This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at twelve months (+/- 30 days) are also included in the denominator.

    CBE ID
    0710e

Depression Response at Six Months- Progress Towards Remission

  • Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate a response to treatment at six months defined as a PHQ-9 score that is reduced by 50% or greater from the initial PHQ-9 score. This measure applies to both patients with newly diagnosed and existing depression identified during the defined measurement period whose current PHQ-9 score indicates a need for treatment.

    CBE ID
    1884