Paper Patient Medical Records

Percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time

All documented patient falls with an injury level of minor or greater on eligible unit types in a calendar quarter. Reported as Injury falls per 1000 Patient Days.

(Total number of injury falls / Patient days) X 1000

Measure focus is safety.
Target population is adult acute care inpatient and adult rehabilitation patients.

This is a clinical process measure that assesses falls prevention in older adults. The measure has three rates:

A) Screening for Future Fall Risk:
Percentage of patients aged 65 years and older who were screened for future fall risk at least once within 12 months



B) Falls Risk Assessment: 
Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months

C) Plan of Care for Falls: 

Percentage of patients with a solid malignant tumor or lymphoma who had a febrile neutropenia (FN) risk assessment completed and documented in the medical record prior to the first cycle of intravenous chemotherapy

This measure calculates the percentage of Emergency Department (ED) acute myocardial infarction (AMI) patients with ST-segment elevation on the electrocardiogram (ECG) closest to arrival time receiving fibrinolytic therapy during the ED stay and having a time from ED arrival to fibrinolysis of 30 minutes or less. The measure is calculated using chart-abstracted data, on a rolling, quarterly basis and is publicly reported, in aggregate, for one calendar year.

Percentage of acute myocardial infarction (AMI) patients with ST-segment elevation or LBBB on the ECG closest to arrival time receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less.

The percentage of Medicaid deliveries that had the following number of expected prenatal visits:

• less than 21 percent of expected visits.

• 21 percent–40 percent of expected visits.

• 41 percent–60 percent of expected visits.

• 61 percent–80 percent of expected visits.

• greater than or equal to 81 percent of expected visits.

Change in rasch derived values of mobility function from admission to discharge among adult LTAC patients aged 18 years and older who were discharged alive. The time frame for the measure is 12 months. The measure includes the following 4 mobility items:Transfer Bed/Chair/Wheelchair, Transfer Toilet, Locomotion and Stairs.

Change in rasch derived values of motor function from admission to discharge among adult short term rehabilitation skilled nursing facility patients aged 18 years and older who were discharged alive. The time frame for the measure is 12 months. The measure includes the following 12 items:Feeding, Grooming, Dressing Upper Body, Dressing Lower Body, Toileting, Bowel, Expression, Memory, Transfer Bed/Chair/Wheelchair, Transfer Toilet, Locomotion and Stairs.

Change in rasch derived values of motor function from admission to discharge among adult long term acute care facility patients aged 18 years and older who were discharged alive. The timeframe for the measure is 12 months. The measure includes the following 12 items:Feeding, Grooming, Dressing Upper Body, Dressing Lower Body, Toileting, Bowel, Expression, Memory, Transfer Bed/Chair/Wheelchair, Transfer Toilet, Locomotion and Stairs.