Paper Records

Number of acute embolus patients who have orders for anticoagulation (heparin or low-molecular weight heparin) for pulmonary embolus while in the ED.

Percent of adult patients who presented within 24 hours of a non-penetrating head injury with a Glasgow coma score (GCS) >13 and underwent head CT for trauma in the ED who have a documented indication consistent with guidelines(1) prior to imaging.

Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with oxygen saturation documented and reviewed

Percentage of patients who are undergoing a biopsy whose biopsy results have been reviewed by the biopsying physician and communicated to the primary care/referring physician and the patient.

Percentage of patients treated for depression who were assessed, prior to treatment, for the presence of current and/or prior manic or hypomanic behaviors.

Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use

Percentage of patients treated for bipolar disorder with evidence of level-of-function evaluation at the time of the initial assessment and again within 12 weeks of initiating treatment

Percentage of infants born to hepatitis B surface antigen (HBsAg)-positive mothers who receive a birth dose of hepatitis B virus (HBV) vaccine and hepatitis B immune globulin (HBIG)

Percentage of pneumonia patients 18 years of age and older who have had blood cultures performed in the emergency department prior to initial antibiotic received in hospital

This measure assesses the proportion of pediatric asthma patients discharged from an inpatient hospital stay with a Home Management Plan of Care (HMPC) document in place. This measure is one of a set of three nationally implemented measures that address children’s asthma care (CAC-1: Relievers for Inpatient Asthma, and CAC-2: Systemic Corticosteroids for Inpatient Asthma) that are used in The Joint Commission’s accreditation process.