|
Quality Id |
Measure Name |
High Priority |
Measure Type |
Measure Description |
|
047 |
Care
Plan |
Yes |
Process |
Percentage
of patients aged 65 years and older who have an advance care plan or
surrogate decision maker documented in the medical record that an advance
care plan was discussed but the patient did not wish or was not able to name
a surrogate decision maker or provide an advance care plan |
|
048 |
Urinary
Incontinence: Assessment of Presence or Absence of Urinary Incontinence in
Women Aged 65 Years and Older |
No |
Process |
Percentage
of female patients aged 65 years and older who were assessed for the presence
or absence of urinary incontinence within 12 months |
|
050 |
Urinary
Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years
and Older |
Yes |
Process |
Percentage
of female patients aged 65 years and older with a diagnosis of urinary
incontinence with a documented plan of care for urinary incontinence at least
once within 12 months |
|
110 |
Preventive
Care and Screening: Influenza Immunization |
No |
Process |
Percentage
of patients aged 6 months and older seen for a visit between October 1 and
March 31 who received an influenza immunization OR who reported previous
receipt of an influenza immunization |
|
112 |
Breast
Cancer Screening |
No |
Process |
Percentage
of women 50-74 years of age who had a mammogram to screen for breast cancer |
|
128 |
Preventive
Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan |
No |
Process |
Percentage
of patients aged 18 years and older with a BMI documented during the current
encounter or during the previous twelve months AND with a BMI outside of
normal parameters, a follow-up plan is documented during the encounter or
during the previous twelve months of the current encounter |
|
130 |
Documentation
of Current Medications in the Medical Record |
Yes |
Process |
Percentage
of visits for patients aged 18 years and older for which the eligible
professional or eligible clinician attests to documenting a list of current
medications using all immediate resources available on the date of the
encounter. This list must include ALL known prescriptions, over-the-counters,
herbals, and vitamin/mineral/dietary (nutritional) supplements AND must
contain the medications’ name, dosage, frequency and route of administration |
|
226 |
Preventive
Care and Screening: Tobacco Use: Screening and Cessation Intervention |
No |
Process |
Percentage
of patients aged 18 years and older who were screened for tobacco use one or
more times within 24 months AND who received tobacco cessation intervention
if identified as a tobacco user |
|
236 |
Controlling
High Blood Pressure |
Yes |
Intermediate
Outcome |
Percentage
of patients 18-85 years of age who had a diagnosis of hypertension and whose
blood pressure was adequately controlled (<140/90mmHg) during the
measurement period |
|
265 |
Biopsy
Follow-Up |
Yes |
Process |
Percentage
of new patients whose biopsy results have been reviewed and communicated to
the primary care/referring physician and patient by the performing physician |
|
317 |
Preventive
Care and Screening: Screening for High Blood Pressure and Follow-Up
Documented |
No |
Process |
Percentage
of patients aged 18 years and older seen during the submitting period who
were screened for high blood pressure AND a recommended follow-up plan is
documented based on the current blood pressure (BP) reading as indicated |
|
374 |
Closing
the Referral Loop: Receipt of Specialist Report |
Yes |
Process |
Percentage
of patients with referrals, regardless of age, for which the referring
provider receives a report from the provider to whom the patient was referred |
|
402 |
Tobacco
Use and Help with Quitting Among Adolescents |
No |
Process |
The
percentage of adolescents 12 to 20 years of age with a primary care visit
during the measurement year for whom tobacco use status was documented and
received help with quitting if identified as a tobacco user |
|
418 |
Osteoporosis
Management in Women Who Had a Fracture |
No |
Process |
The
percentage of women age 50-85 who suffered a fracture and who either had a
bone mineral density test or received a prescription for a drug to treat
osteoporosis in the six months after the fracture |
|
422 |
Performing
Cystoscopy at the Time of Hysterectomy for Pelvic
Organ Prolapse to Detect Lower Urinary Tract Injury |
Yes |
Process |
Percentage
of patients who undergo cystoscopy to evaluate for
lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse |
|
428 |
Pelvic
Organ Prolapse: Preoperative Assessment of Occult
Stress Urinary Incontinence |
No |
Process |
Percentage
of patients undergoing appropriate preoperative evaluation of stress urinary
incontinence prior to pelvic organ prolapse surgery
per ACOG/AUGS/AUA guidelines |
|
429 |
Pelvic
Organ Prolapse: Preoperative Screening for Uterine
Malignancy |
Yes |
Process |
Percentage
of patients who are screened for uterine malignancy prior to vaginal closure
or obliterative surgery for pelvic organ prolapse |
|
431 |
Preventive
Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling |
No |
Process |
Percentage
of patients aged 18 years and older who were screened for unhealthy alcohol
use using a systematic screening method at least once within the last 24
months AND who received brief counseling if identified as an unhealthy
alcohol user |
|
432 |
Proportion
of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair |
Yes |
Outcome |
Percentage
of patients undergoing any surgery to repair pelvic organ prolapse
who sustains an injury to the bladder recognized either during or within 1
month after surgery |
|
433 |
Proportion
of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair |
Yes |
Outcome |
Percentage
of patients undergoing surgical repair of pelvic organ prolapse
that is complicated by a bowel injury at the time of index surgery that is
recognized intraoperatively or within 1 month after
surgery |
|
434 |
Proportion
of Patients Sustaining a Ureter Injury at the Time
of any Pelvic Organ Prolapse Repair |
Yes |
Outcome |
Percentage
of patients undergoing pelvic organ prolapse
repairs who sustain an injury to the ureter
recognized either during or within 1 month after surgery |
|
443 |
Non-Recommended
Cervical Cancer Screening in Adolescent Females |
No |
Process |
The
percentage of adolescent females 16–20 years of age screened unnecessarily
for cervical cancer |
|
447 |
Chlamydia
Screening and Follow Up |
No |
Process |
The
percentage of female adolescents 16 years of age who had a chlamydia screening test with proper follow-up during the
measurement period |
|
448 |
Appropriate
Work Up Prior to Endometrial Ablation |
Yes |
Process |
Percentage
of women, aged 18 years and older, who undergo endometrial sampling or
hysteroscopy with biopsy and results documented before undergoing an
endometrial ablation |