1. Females age 23-64
years old with 1 or
more cervical cancer
screenings within
reporting year or the
previous 2 years
1
0%
10%
20%
30%
40%
50%
60%
70%
70%
51.42%
58.57%
Goal Jan-17 May-17
2. Patients ages 50-75
years old with
colorectal cancer
screening as
appropriate
2
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
42%
27.14%
47.14%
Goal Jan-17 May-17
3. Tobacco users age 18
years or older who
received cessation
counseling or
medication
3
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
90% 88.57% 98.57%
Goal Jan-17 May-17
5. Patients ages 12 or
older who were
screened for
depression and had a
follow-up plan
documented if they
were considered
depressed
5
0%
10%
20%
30%
40%
50%
60%
70%
80% 75%
55.71%
74.28%
Goal Jan-17 May-17
6. Patients age 18 or
older with BMI &
Follow-Up plan for
patients who are over
or underweight
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
88%
82.85%
65.71%
Goal Jan 2017 May 2017
6
7. Patients ages 5-64
years old diagnosed
with persistent asthma
who have an
acceptable
pharmacological
treatment plan
7
78%
80%
82%
84%
86%
88%
90%
92%
94%
84%
92.85%
85.71%
Goal Jan-17 May-17
10. Children who have
been properly
immunized by 2 years
of age
10
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
60%
44.68%
90.00%
Goal Jan-17 May-17
11. Percentage of patients
age 18 years or older,
with diagnosis of IVD,
AMI, CABG or PTCA
procedure with aspirin
or other antithrombotic
therapy
11
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
88%
77.71%
89.36%
Goal Jan-17 May-17
12. Patients age 18 years
or older with CAD and
prescribed lipid
lowering therapy
12
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
88%
75.77%
80.76%
Goal Jan-17 May-17
13. Percentage of patients
first diagnosed with
HIV by CFHC, Inc. and
were seen for follow-
up within 90 days of
diagnosis
13
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
100% 100.00% 100.00%
Goal Jan-17 May-17
14. Children ages 6-9
years old who are at
moderate to high risk
for caries and have
received dental
sealants on their first
permanent molars
14
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
70%
81.25%
33.30%
Goal Jan-17 May-17
Editor's Notes
There were also some charts where the tobacco use status in the note did not match the tobacco use status on the facesheet. Nurses need to be reminded that when querying the patient to record the tobacco use status under the social history section of the facesheet. It is also very helpful if they enter the screening date.
This is a process measure as well. The less poorly controlled diabetic patients the better.
Please make sure to add verbiage to notes when a patient is referred to IBH due to a high depression screening score.
ICD-9 (ICD-10) codes: V65.41 (Z71.89) Exercise counseling; V65.3 (Z71.3) Dietary surveillance and counseling. It was also identified that either the height or weight was not recorded. This is needed so that the system can calculate the BMI. The audit focuses on those patients whose BMI is outside of normal range and is provided diet and/or nutrition counseling. Credit is also given if education and nutrition handouts are given to patients.
Please remember to update the patient’s problem list.
This is a reverse measure. Our goal is to have more of our hypertensive patients with controlled blood pressures, rather than measuring those patients with uncontrolled blood pressure.
Documentation should be made in the note if a parent refuses immunizations for their children. This will allow me to document this information to provide to HRSA so that we can prove that we are offering immunizations but the parents are declining. Please remember that Hepatitis A, 2-3 Rotavirus and 2 Flu vaccines were added to the performance measure.
Have nurses record outside medications with the date listed on the prescription bottle, hospital discharge information.
Have nurses record outside medications with the date listed on the prescription bottle, hospital discharge information.
There were no newly diagnosed patients identified by CFHC, Inc. during the reporting measure.
Please keep in mind that even if a patient is at moderate or high risk of carries and referred out but not given sealants it does count negatively against us.
