Electronic Health Records: Electronic Health Records

This measure is based on data from MDS 3.0 assessments of long-stay nursing facility residents. The measure reports the percentage of all long-stay residents 5 years and older who were assessed and appropriately given the Pneumococcal Vaccination as reported on the target MDS assessment (OBRA, PPS or discharge) during the 12-month reporting period. This proposed measure is harmonized with NQF’s quality measure on Pneumococcal Immunizations.(1) The MDS 3.0 definitions have been changed to conform to the NQF standard.

The measure reports the percentage of short stay nursing home residents or IRF or LTCH patients who were assessed and appropriately given the pneumococcal vaccine during the 12-month reporting period.

This measure is based on data from MDS 3.0 assessments of nursing home residents. Either a resident interview measure or a staff assessment measure will be reported. The preferred version is the resident interview measure. The resident interview measure will be used unless either there are three or more missing sub-items needed for calculation or the resident is rarely or never understood, in which cases the staff assessment measure will be calculated and used. These measures use those questions in MDS 3.0 that comprise the Patient Health Questionnaire (PHQ-9) depression instrument.

This measure reports the percentage of long-stay nursing home residents with a target Minimum Data Set (MDS) assessment (OBRA, PPS, Discharge) that indicates a weight loss of 5% or more of the baseline weight in the last 30 days or 10% or more of the baseline weight in the last 6 months, which is not a result of a physician-prescribed weight-loss regimen. The baseline weight is the resident’s weight closest to 30 or 180 days before the date of the target assessment. Long-stay residents are identified as residents who have had at least 101 cumulative days of nursing facility care.

The measure reports the percentage of all long-stay residents who were physically restrained daily during the 7 days prior to the target MDS 3.0 assessment (OBRA, PPS or discharge) during their episode of nursing home care ending in the target quarter (3-month period). Long-stay residents are identified as residents who have had at least 101 cumulative days of nursing facility care.

This measure, based on data from the Minimum Data Set (MDS) 3.0 assessment of long-stay nursing facility residents, estimates the percentage of long-stay residents in a nursing facility whose need for assistance with late-loss Activities of Daily Living (ADLs), as reported in the target assessment, increased when compared with a prior assessment. The four late-loss ADLs are: bed mobility, transfer, eating, and toilet use.

The proportion of in-center hemodialysis, home hemodialysis, and peritoneal dialysis patients who have documentation of receiving a new post-dialysis weight prescription from a nephrologist in the reporting month, irrespective of whether or not a change in post dialysis weight prescription was made.

Percentage of surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time

Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time

Percentage of all adult (>= 18 years old) peritoneal dialysis patients with total solute clearance for urea (endogenous residual renal urea clearance & dialytic) measured at least once in a four month time period.