Beta-blocker therapy not prescribed, reason not given

Beta-blocker therapy prescribed or currently being taken

Documentation of medical reason(s) for not prescribing beta-blocker therapy (eg, allergy, intolerance, other medical reasons)

Documentation of patient reason(s) for not prescribing beta-blocker therapy (eg, patient declined, other patient reasons)

Documentation of system reason(s) for not prescribing beta-blocker therapy (eg, other reasons attributable to the health care system)

Clinician documented that patient with a diagnosis of major depression was not an eligible candidate for antidepressant medication treatment or patient did not have a diagnosis of major depression

Patient with a diagnosis of major depression documented as being treated with antidepressant medication during the entire 180 day (6 month) continuation treatment phase

Patient with a diagnosis of major depression not documented as being treated with antidepressant medication during the entire 180 day (6 months) continuation treatment phase

Documentation of medical reason(s) for not ordering a first or second generation cephalosporin for antimicrobial prophylaxis (e.g., patients enrolled in clinical trials, patients with documented infection prior to surgical procedure of interest, patients who were receiving antibiotics more than 24 hours prior to surgery [except colon surgery patients taking oral prophylactic antibiotics], patients who were receiving antibiotics within 24 hours prior to arrival [except colon surgery patients taking oral prophylactic antibiotics], other medical reason(s))

Documentation of order for first or second generation cephalosporin for antimicrobial prophylaxis

Order for first or second generation cephalosporin for antimicrobial prophylaxis was not documented, reason not given

Venous thromboembolism (vte) prophylaxis not administered the day of or the day after hospital admission for documented reasons (eg, patient is ambulatory, patient expired during inpatient stay, patient already on warfarin or another anticoagulant, other medical reason(s) or eg, patient left against medical advice, other patient reason(s))

Venous thromboembolism (vte) prophylaxis was not administered the day of or the day after hospital admission, reason not given

Venous thromboembolism (vte) prophylaxis administered the day of or the day after hospital admission

Patients with a positive hepatitis c antibody test

Rna testing for hepatitis c documented as performed within 12 months prior to initiation of antiviral treatment for hepatitis c

Rna testing for hepatitis c was not documented as performed within 12 months prior to initiation of antiviral treatment for hepatitis c, reason not given

Patient starting antiviral treatmentfor hepatitis c during the measurement period

Patient starting antiviral treatment for hepatitis c during the measurement period

Hepatitis c genotype testing documented as performed within 12 months prior to initiation of antiviral treatment for hepatitis c

Hepatitis c genotype testing was not documented as performed within 12 months prior to initiation of antiviral treatment for hepatitis c, reason not given

Hepatitis c quantitative rna testing documented as performed between 4-12 weeks after the initiation of antiviral treatment

Hepatitis c quantitative rna testing not performed between 4-12 weeks after the initiation of antiviral treatment for documented reason(s) (e.g., patients whose treatment was discontinued during the testing period prior to testing, other medical reasons, patient declined, other patient reasons)

Hepatitis c quantitative rna testing was not documented as performed between 4-12 weeks after the initiation of antiviral treatment, reason not given

Dsm-ivtm criteria for major depressive disorder documented at the initial evaluation

Dsm-iv-tr criteria for major depressive disorder not documented at the initial evaluation, reason not otherwise specified

Cd4+ cell count or cd4+ cell percentage results documented

Cd4+ cell count or percentage not documented as performed, reason not given

Pcp prophylaxis was not prescribed at time of diagnosis of hiv, reason not given

Pcp prophylaxis was not prescribed within 3 months of low cd4+ cell count below 200 cells/mm3, reason not given

Pcp prophylaxis was not prescribed within 3 months oflow cd4+ cell count below 500 cells/mm3 or a cd4 percentage below 15%, reason not given

Pneumocystis jiroveci pneumonia prophylaxis not prescribed within 3 months of low cd4+ cell count below 200 cells/mm3 for medical reason (i.e., patient's cd4+ cell count above threshold within 3 months after cd4+ cell count below threshold, indicating that the patient's cd4+ levels are within an acceptable range and the patient does not require pcp prophylaxis)

Pneumocystis jiroveci pneumonia prophylaxis not prescribed within 3 months of low cd4+ cell count below 500 cells/mm3 or a cd4 percentage below 15% for medical reason (i.e., patient's cd4+ cell count above threshold within 3 months after cd4+ cell count below threshold, indicating that the patient's cd4+ levels are within an acceptable range and the patient does not require pcp prophylaxis)

Pneumocystis jiroveci pneumonia prophlaxis prescribed

Pneumocystis jiroveci pneumonia prophylaxis prescribed wthin 3 months of low cd4+ cell count below 200 cells/mm3

Pneumocystis jiroveci pneumonia prophylaxis prescribed within 3 months of low cd4+ cell count below 500 cells/mm3 or a cd4 percentage below 15%

Documentation of medical reason for not performing foot exam (e.g., patient with bilateral foot/leg amputation)

Foot exam was not performed, reason not given

Foot examination performed (includes examination through visual inspection, sensory exam with 10-g monofilament plus testing any one of the following: vibration using 128-hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold, and pulse exam; report when all of the 3 components are completed)

Functional outcome assessment documented, care plan not documented, documentation the patient is not eligible for a care plan at the time of the encounter

Chlamydia, gonorrhea and syphilis screening results documented (report when results are present for all of the 3 screenings)

Chlamydia, gonorrhea, and syphilis screening results not documented (patient refusal is the only allowed exception)

Chlamydia, gonorrhea, and syphilis not screened, reason not given

Documentation of end stage renal disease (esrd), dialysis, renal transplant before or during the measurement period or pregnancy during the measurement period

Clinician treating major depressive disorder did not communicate to clinician treating comorbid condition for specified patient reason (e.g., patient is unable to communicate the diagnosis of a comorbid condition; the patient is unwilling to communicate the diagnosis of a comorbid condition; or the patient is unaware of the comorbid condition, or any other specified patient reason)

All quality actions for the applicable measures in the total knee replacement measures group have been performed for this patient

I intend to report the total knee replacement measures group

All quality actions for the applicable measures in the general surgery measures group have been performed for this patient

All quality actions for the applicable measures in the optimizing patient exposure to ionizing radiation measures group have been performed for this patient

I intend to report the general surgery measures group

I intend to report the optimizing patient exposure to ionizing radiation measures group

Documentation of reasons for patient initiating maintenance hemodialysis with a catheter as the mode of vascular access (e.g., patient has a maturing arteriovenous fistula (avf)/arteriovenous graft (avg), time-limited trial of hemodialysis, other medical reasons, patient declined avf/avg, other patient reasons, patient followed by reporting nephrologist for fewer than 90 days, other system reasons)

Patient whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated

Patient whose mode of vascular access is not a catheter at the time maintenance hemodialysis is initiated

Documentation of viral load equal to or greater than 200 copies/ml or viral load not performed

Documentation of viral load less than 200 copies/ml

Antiretroviral thereapy not prescribed

Antiretroviral therapy prescribed

Patient did not have at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits

Patient had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits

Patient did not have a medical visit in the last 6 months

Patient had a medical visit in the last 6 months

Documentation of patient pain brought to a comfortable level within 48 hours from initial assessment

Documentation of patient with pain not brought to a comfortable level within 48 hours from initial assessment

Adenoma(s) or other neoplasm detected during screening colonoscopy

Adenoma(s) or other neoplasm not detected during screening colonoscopy

Documentation of patient discharged to home later than post-operative day 2 following cas

Documentation of patient discharged to home no later than post operative day 2 following cas

Documentation of patient death following cas

Documentation of patient stroke following cas

Documentation of patient stroke following cea

Documentation of patient survival and absence of stroke following cas

Documentation of patient death following cea

Documentation of patient survival and absence of stroke following cea

Documentation of patient death in the hospital following endovascular aaa repair

Documentation of patient discharged alive following endovascular aaa repair

Documentation of patient receiving maintenance hemodialysis for greater than or equal to 90 days with a catheter for documented reasons (e.g., other medical reasons, patient declined arteriovenous fistula (avf)/arteriovenous graft (avg), other patient reasons)

Patient receiving maintenance hemodialysis for greater than or equal to 90 days with a catheter as the mode of vascular access

Patient receiving maintenance hemodialysis for greater than or equal to 90 days without a catheter as the mode of vascular access

Documentation of patient with one or more complications or mortality within 30 days

Documentation of patient with one or more complications within 90 days

Documentation of patient without one or more complications and without mortality within 30 days

Documentation of patient without one or more complications within 90 days

Ldl value < 100

Ldl value >= 100

Blood pressure has a systolic value of < 140 and a diastolic value of < 90

Blood pressure has a systolic value of =140 and a diastolic value of = 90 or systolic value < 140 and diastolic value = 90 or systolic value = 140 and diastolic value < 90

Documentation that patient is a current non-tobacco user

Documentation that patient is a current tobacco user

Documentation that the patient is on daily aspirin or anti-platelet or has documentation of a valid contraindication or exception to aspirin/anti-platelet; contraindications/exceptions include anti-coagulant use, allergy to aspirin or anti-platelets, history of gastrointestinal bleed and bleeding disorder; additionally, the following exceptions documented by the physician as a reason for not taking daily aspirin or anti-platelet are acceptable (use of non-steroidal anti-inflammatory agents, documented risk for drug interaction, uncontrolled hypertension defined as >180 systolic or >110 diastolic or gastroesophageal reflux)

Documentation that the patient is not on daily aspirin or anti-platelet regimen

Pneumococcal screening performed and documentation of vaccination received prior to discharge

Pneumococcal vaccination not administered prior to discharge, reason not specified

Screening performed and documentation that vaccination not indicated/patient refusal

Documentation of medical reason(s) for not reporting the histological type or nsclc-nos classification with an explanation (e.g., biopsy taken for other purposes in a patient with a history of non-small cell lung cancer or other documented medical reasons)

Non small cell lung cancer biopsy and cytology specimen report documents classification into specific histologic type or classified as nsclc-nos with an explanation

Non small cell lung cancer biopsy and cytology specimen report does not document classification into specific histologic type or classified as nsclc-nos with an explanation

Specimen site other than anatomic location of lung or is not classified as non small cell lung cancer

Antibiotic regimen prescribed within 10 days after onset of symptoms

Antibiotic regimen not prescribed within 10 days after onset of symptoms

Documentation of medical reason(s) for not reporting the histological type or nsclc-nos classification with an explanation (e.g., a solitary fibrous tumor in a person with a history of non-small cell carcinoma or other documented medical reasons)

Non small cell lung cancer biopsy and cytology specimen report documents classification into specific histologic type or classified as nsclc-nos with an explanation

Non small cell lung cancer biopsy and cytology specimen report does not document classification into specific histologic type or classified as nsclc-nos with an explanation

Specimen site other than anatomic location of lung, is not classified as non small cell lung cancer or classified as nsclc-nos

Documentation of medical reason(s) for not reporting pt category and a statement on thickness and ulceration and for pt1, mitotic rate (e.g., negative skin biopsies in a patient with a history of melanoma or other documented medical reasons)

Pathology report does not include the pt category and a statement on thickness and ulceration and for pt1, mitotic rate

Pathology report includes the pt category and a statement on thickness and ulceration and for pt1, mitotic rate

Specimen site other than anatomic cutaneous location

Patients with documented shared decision-making including discussion of conservative (non-surgical) therapy (e.g., nsaids, analgesics, weight loss, exercise, injections) prior to the procedure

Shared decision-making including discussion of conservative (non-surgical) therapy (e.g., nsaids, analgesics, weight loss, exercise, injections) prior to the procedure, not documented, reason not given

Patients who are evaluated for venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g., history of dvt, pe, mi, arrhythmia and stroke)

Patients who are not evaluated for venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure including (e.g., history of dvt, pe, mi, arrhythmia and stroke, reason not given)

Documentation of medical reason(s) for not completely infusing the prophylactic antibiotic prior to the inflation of the proximal tourniquet (e.g., a tourniquet was not used)

Patients who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet

Prophylactic antibiotic not completely infused prior to the inflation of the proximal tourniquet, reason not given

Operative report does not identify the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant, reason not given

Operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant

Intervention for presence of leak of endoluminal contents through an anastomosis not required

Intervention for presence of leak of endoluminal contents through an anastomosis required

No return to the operating room for a surgical procedure, for complications of the principal operative procedure, within 30 days of the principal operative procedure

Unplanned return to the operating room for a surgical procedure, for complications of the principal operative procedure, within 30 days of the principal operative procedure

No unplanned hospital readmission within 30 days of principal procedure

Unplanned hospital readmission within 30 days of principal procedure

No surgical site infection

Surgical site infection

Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time of diagnosis for documented reason

Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time of diagnosis, reason not given

Documentation amoxicillin, with or without clavulanate, prescribed as a first line antibiotic at the time of diagnosis

Documentation of patient-specific risk assessment with a risk calculator based on multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient or family

Documentation of patient-specific risk assessment with a risk calculator based on multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient or family not completed

Imaging study named according to standardized nomenclature

Imaging study not named according to standardized nomenclature, reason not given

Documentation of medical reason(s) for not naming ct studies according to a standardized nomenclature provided (eg, ct studies performed for radiation treatment planning or image-guided radiation treatment delivery)

Count of previous ct (any type of ct) and cardiac nuclear medicine (myocardial perfusion) studies documented in the 12-month period prior to the current study

Count of previous ct and cardiac nuclear medicine (myocardial perfusion) studies not documented in the 12-month period prior to the current study, reason not given

Documentation of medical reason(s) for not counting previous ct and cardiac nuclear medicine (myocardial perfusion) studies (eg, ct studies performed for radiation treatment planning or image-guided radiation treatment delivery)

All necessary data elements not included, reason not given

Ct studies not reported to a radiation dose index registry due to medical reasons (eg, ct studies performed for radiation treatment planning or image-guided radiation treatment delivery)

Ct studies performed not reported to a radiation dose index registry that is capable of collecting at a minimum all necessary data elements, reason not given

Ct studies performed reported to a radiation dose index registry that is capable of collecting at a minimum all necessary data elements

Dicom format image data availability not documented in final report due to medical reasons (eg, ct studies performed for radiation treatment planning or image-guided radiation treatment delivery)

Dicom format image data available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study not documented in final report, reason not given

Final report documented that dicom format image data available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study

Search conducted for prior patient ct studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being performed

Search not conducted prior to an imaging study being performed for prior patient ct studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media-free, shared archive, reason not given

Due to medical reasons, search not conducted for dicom format images for prior patient ct imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12 months that are available through a secure, authorized, media-free, shared archive (e.g., ct studies performed for radiation treatment planning or image-guided radiation treatment delivery)

Due to system reasons search not conducted for dicom format images for prior patient ct imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12 months that are available through a secure, authorized, media-free, shared archive (e.g., non-affiliated external healthcare facilities or entities does not have archival abilities through a shared archival system)

Follow-up recommendations documented according to recommended guidelines for incidentally detected pulmonary nodules (e.g., follow-up ct imaging studies needed or that no follow-up is needed) based at a minimum on nodule size and patient risk factors

Follow-up recommendations not documented according to recommended guidelines for incidentally detected pulmonary nodules due to medical reasons (e.g., patients with known malignant disease, patients with unexplained fever, ct studies performed for radiation treatment planning or image-guided radiation treatment delivery)

Follow-up recommendations not documented according to recommended guidelines for incidentally detected pulmonary nodules, reason not given

Ct scan of the paranasal sinuses ordered at the time of diagnosis for documented reasons

Ct scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis

Ct scan of the paranasal sinuses not ordered at the time of diagnosis or received within 28 days after date of diagnosis

More than one ct scan of the paranasal sinuses ordered or received within 90 days after diagnosis

More than one ct scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis, reason not given

More than one ct scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis for documented reasons (eg, patients with complications, second ct obtained prior to surgery, other medical reasons)

One ct scan or no ct scan of the paranasal sinuses ordered within 90 days after the date of diagnosis

Early elective delivery or early induction not performed (less than 39 weeks gestation)

Early elective delivery or early induction performed (less than 39 week gestation)

Post-partum screenings, evaluations and education performed

Post-partum screenings, evaluations and education not performed

Documentation of negative or managed positive tb screen with further evidence that tb is not active prior to the treatment with a biologic immune response modifier

No documentation of negative or managed positive tb screen

Medical indication for induction [documentation of reason(s) for elective delivery (c-section) or early induction (e.g., hemorrhage and placental complications, hypertension, preeclampsia and eclampsia, rupture of membranes-premature or prolonged, maternal conditions complicating pregnancy/delivery, fetal conditions complicating pregnancy/delivery, late pregnancy, prior uterine surgery, or participation in clinical trial)]

Duration of monitored anesthesia care (mac) or peripheral nerve block (pnb) without the use of general anesthesia during an applicable procedure 60 minutes or longer, as documented in the anesthesia record

Duration of monitored anesthesia care (mac) or peripheral nerve block (pnb) without the use of general anesthesia during an applicable procedure or general or neuraxial anesthesia less than 60 minutes, as documented in the anesthesia record

Sinusitis caused by, or presumed to be caused by, bacterial infection

One high-risk medication ordered

One high-risk medication not ordered

At least two orders for the same high-risk medication

At least two orders for the same high-risk medications not ordered

Individual filled at least two prescriptions for any antipsychotic medication and had a pdc of 0.8 or greater

Individual who did not fill at least two prescriptions for any antipsychotic medication or did not have a pdc of 0.8 or greater

Patient continued to have the retina attached at the 6 months follow up visit (+/- 1 month) following only one surgery

Patient did not have the retina attached after 6 months following only one surgery

Patient continued to have the retina attached at the 6 months follow up visit (+/- 1 month)

Patient did not achieve flat retinas six months post surgery

Patient offered assistance with end of life issues during the measurement period

Documentation of medical reason(s) for not offering assistance with end of life issues (e.g., patient in hospice care, patient in terminal phase) during the measurement period

Patient not offered assistance with end of life issues during the measurement period

Patient received screening for hcv infection within the 12 month reporting period

Documentation of medical reason(s) for not receiving annual screening for hcv infection (e.g., decompensated cirrhosis indicating advanced disease [i.e., ascites, esophageal variceal bleeding, hepatic encephalopathy], hepatocellular carcinoma, waitlist for organ transplant, limited life expectancy, other medical reasons)

Documentation of patient reason(s) for not receiving annual screening for hcv infection (e.g., patient declined, other patient reasons)

Screening for hcv infection not received within the 12 month reporting period, reason not given

Unplanned rupture of the posterior capsule requiring vitrectomy during cataract surgery

No unplanned rupture of the posterior capsule requiring vitrectomy during cataract surgery

Patient achieves refraction +-1 d for the eye that underwent cataract surgery, measured at the one month follow up visit

Patient does not achieve refraction +-1 d for the eye that underwent cataract surgery, measured at the one month follow up visit

Patient with an initial phq-9 score greater than nine who achieves remission at twelve months as demonstrated by a twelve month (+/- 30 days) phq-9 score of less than five

Patient who had a diagnosis of bipolar disorder or personality disorder, death, permanent nursing home resident or receiving hospice or palliative care any time during the measurement or assessment period

Patient with an initial phq-9 score greater than nine who did not achieve remission at twelve months as demonstrated by a twelve month (+/- 30 days) phq-9 score greater than or equal to five

Patient with an initial phq-9 score greater than nine who was not assessed for remission at twelve months (+/- 30 days)

Documentation in the patient record of a discussion between the physician/clinician and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward the outcome of the treatment

Documentation of medical or patient reason(s) for not discussing treatment options; medical reasons: patient is not a candidate for treatment due to advanced physical or mental health comorbidity (including active substance use); currently receiving antiviral treatment; successful antiviral treatment (with sustained virologic response) prior to reporting period; other documented medical reasons; patient reasons: patient unable or unwilling to participate in the discussion or other patient reasons

No documentation of a discussion in the patient record of a discussion between the physician or other qualfied healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment

Patient received follow-up on the date of discharge or within 30 days after discharge

Clinician documented reason patient was not able to complete 30 day follow-up from acute inpatient setting discharge (e.g., patient death prior to follow-up visit, patient non-compliant for visit follow-up)

Patient did not receive follow-up on the date of discharge or within 30 days after discharge

Patient received follow-up within 7 days after discharge

Clinician documented reason patient was not able to complete 7 day follow-up from acute inpatient setting discharge (i.e patient death prior to follow-up visit, patient non-compliance for visit follow-up)

Patient did not receive follow-up on or within 7 days after discharge

Patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days

Patients without cardiac tamponade and/or pericardiocentesis occurring within 30 days

Patient admitted within 180 days, status post cied implantation, replacement, or revision with an infection requiring device removal or surgical revision

Patient not admitted within 180 days, status post cied implantation, replacement, or revision with an infection requiring device removal or surgical revision

Patient admitted within 180 days, status post cied implantation, replacement, or revision with an infection requiring device removal or surgical revision

Patient not admitted within 180 days, status post cied implantation, replacement, or revision with an infection requiring device removal or surgical revision

Patient had one dose of meningococcal vaccine (serogroups a, c, w, y) on or between the patient's 11th and 13th birthdays

Patient did not have one dose of meningococcal vaccine on or between the patient's 11th and 13th birthdays

Patient had one tetanus, diphtheria toxoids and acellular pertussis vaccine (tdap) on or between the patient's 10th and 13th birthdays

Patient did not have one tetanus, diphtheria toxoids and acellular pertussis vaccine (tdap) on or between the patient's 10th and 13th birthdays

Primary non-small cell lung cancer biopsy and cytology specimen report documents classification into specific histologic type or classified as nsclc-nos with an explanation

Documentation of medical reason(s) for not including the histological type or nsclc-nos classification with an explanation (e.g., biopsy taken for other purposes in a patient with a history of primary non-small cell lung cancer or other documented medical reasons)

Specimen site other than anatomic location of lung or is not classified as primary non-small cell lung cancer

Primary non-small cell lung cancer biopsy and cytology specimen report does not document classification into specific histologic type or classified as nsclc-nos with an explanation

Primary lung carcinoma resection report documents pt category, pn category and for non-small cell lung cancer, histologic type (squamous cell carcinoma, adenocarcinoma and not nsclc-nos)

Documentation of medical reason for not including pt category, pn category and histologic type [for patient with appropriate exclusion criteria (e.g., metastatic disease, benign tumors, malignant tumors other than carcinomas, inadequate surgical specimens)]

Specimen site other than anatomic location of lung, or classified as nsclc-nos

Primary lung carcinoma resection report does not document pt category, pn category and for non-small cell lung cancer, histologic type (squamous cell carcinoma, adenocarcinoma)

Improvement in median time from ed arrival to initial ed oral or parenteral pain medication administration performed for ed admitted patients

Improvement in median time from ed arrival to initial ed oral or parenteral pain medication administration not performed for ed admitted patients

Pathology report includes the pt category and a statement on thickness, ulceration and mitotic rate

Documentation of medical reason(s) for not including pt category and a statement on thickness, ulceration and mitotic rate (e.g., negative skin biopsies in a patient with a history of melanoma or other documented medical reasons)

Specimen site other than anatomic cutaneous location

Pathology report does not include the pt category and a statement on thickness, ulceration and mitotic rate

Asthma well-controlled based on the act, c-act, acq, or ataq score and results documented

Death, permanent nursing home resident or receiving hospice or palliative care any time during the measurement period

Asthma not well-controlled based on the act, c-act, acq, or ataq score, or specified asthma control tool not used, reason not given

Aspirin prescribed at discharge

Aspirin not prescribed for documented reasons (e.g., allergy, medical intolerance, history of bleed)

Aspirin not prescribed at discharge

P2y inhibitor prescribed at discharge

P2y inhibitor not prescribed for documented reasons (e.g., allergy, medical intolerance, history of bleed)

P2y inhibitor not prescribed at discharge

Statin prescribed at discharge

Statin not prescribed for documented reasons (e.g., allergy, medical intolerance)

Statin not prescribed at discharge

Patients who were born in the years 1945?1965

History of receiving blood transfusions prior to 1992

History of injection drug use

Patient received one-time screening for hcv infection

Documentation of medical reason(s) for not receiving one-time screening for hcv infection (e.g., decompensated cirrhosis indicating advanced disease [ie, ascites, esophageal variceal bleeding, hepatic encephalopathy], hepatocellular carcinoma, waitlist for organ transplant, limited life expectancy, other medical reasons)