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Paper Patient Medical Records

Valid for Measure Submission

Emergency Transfer Communication Measure

Percentage of all patients transferred from an Emergency Department to another healthcare facility whose medical record documentation indicated that all required information was communicated (sent) to the receiving facility within 60 minutes of transfer For all data elements, the definition of ‘sent’ includes the following:
• Hard copy sent directly with the patient, or 
• Sent via fax or phone within 60 minutes of patient departure, or
• Immediately available via shared Electronic health record (EHR) or Health Information Exchange (HIE) (see definition below)

CBE ID
0291

Evaluation of Left ventricular systolic function (LVS)

Percentage of heart failure patients with documentation in the hospital record that left ventricular systolic (LVS) function was evaluated before arrival, during hospitalization, or is planned for after discharge.

CBE ID
0135

Falls with injury

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.

CBE ID
0202

Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls

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: 

CBE ID
0101

Febrile Neutropenia Risk Assessment Prior to Chemotherapy

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

CBE ID
2930

Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival

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.

CBE ID
0288

Fibrinolytic Therapy received within 30 minutes of hospital arrival

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.

CBE ID
0164

Frequency of Ongoing Prenatal Care (FPC)

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.

CBE ID
1391

Functional Change: Change in Mobility Score for Long Term Acute Care Facilities

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.

CBE ID
2778