Emergency Department (Ed) / Immunization (Imm) Alphabetical Paper Tool

Emergency Department (Ed) / Immunization (Imm) Alphabetical Paper Tool

Immunization (IMM)

Paper Tool for Discharge Measure Influenza Immunization (IMM-2)

01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)

This paper abstraction tool is provided as an optional, informal mechanism to aid psychiatric facilities and hospital psychiatric units in the collection of the measures for the CMS Inpatient Psychiatric Facility Quality Reporting Program. The tool is designed to collect patient specific data; however, once abstracted the data will need to be compiled and reported to CMS in aggregate.It should be noted that skip logic is not contained within the paper abstraction tool. If there are any questions or concerns regarding use of this paper abstraction tool, please contact the IPFQR Program Support Contractor .

Birthdate:______/______/______

UTD is not an allowable entry

Patient Identifier: ______

Admission Date: ______/______/______

UTD is not an allowable entry

Discharge Date: ______/______/______

UTD is not an allowable entry

Individual Medical Record Data Collection Tool

During review of the record, the abstractor will be prompted to enter a 0 or a 1 for both the numerator and denominator for the measure below.

Patient Level - IMM-2

______Numerator

______Denominator

The information from each medical record will be used to determine the numerator and denominator which will be aggregated for submission to QualityNet.

IMM-2

  1. What is the patient’s age? Patient Age (in years) is calculated by Admission Dateminus Birthdate.______
  1. If Patient Ageis less than 6 months old, then the case will be excluded (Measure Category Assignment of “B”).Stop abstracting. The case will not be included in the numerator or denominator for IMM-2.Add 0 to the numerator and denominator for IMM-2.
  2. If Patient Ageis 6 months or greater, thencontinue abstracting and proceed to ICD-9-CM Principal and ICD-9-CMOther Procedure Codes.
  1. What was the ICD-9-CM code selected as the principal procedure for this record?(ICD-9-CM Principal Procedure Code)______

What was the ICD-9-CM code(s) selected as the other procedure for this record?(ICD-9-CM Other Procedure Codes) ______

a.If at least one code above is on Table 12.10, then the case will be excluded (Measure Category Assignment of “B”). Stop abstracting. The case will not be included in the numerator or denominator for IMM-2. Add 0 to the numerator and denominator for IMM-2.

b.If none of the codes above areon Table 12.10, thencontinue abstracting and proceed to Discharge Disposition.

  1. What was the patient’s discharge disposition on the day of discharge?

(Discharge Disposition)

_____1Home

_____2Hospice – Home

_____3Hospice – Health Care Facility

_____4Acute Care Facility

_____5Other Health Care Facility

_____6Expired

_____7Left Against Medical Advice (AMA)

_____8Not Documented or Unable to Determine (UTD)

a.If Discharge Disposition Status equals 4, 6, or 7, then the case will be excluded (Measure Category Assignment of “B”). Stop abstracting.The case will not be included in the numerator or denominator for IMM-2.Add 0 to the numerator and denominator for IMM-2.

b.If Discharge Disposition Status equals 1, 2, 3, 5, or 8, thencontinue abstracting and proceed to Discharge Date.

4.Discharge Date: ______/______/______ All dates are in MM-DD-YYYY (UTD is not allowable entry)

a.If the discharge date is 10-01-yyyy through 03-31-yyyy, then continue abstracting and proceed to ICD-9-CM Principal andICD-9-CM Other Procedure Codes.

b.If the discharge date is 04-01-yyyy through 09-30-yyyy, then the case will be excluded (Measure Category Assignment of “B”). Stop abstracting. The case will not be included in the numerator or denominator for IMM-2. Add 0 to the numerator and denominator for IMM-2.

5.Refer to the ICD-9-CM Principal or Other Procedure Codes listed in #2. (ICD-9-CM Principal or ICD-9-CMOther Procedure Codes)

a.If none of the codes above areon Table 12.9, continueand proceed to Influenza Vaccination Status.

b.If at least one code above is on Table 12.9, the case will be included (Measure Category Assignment of “E”). Stop abstracting. Add 1 to BOTH the numerator and denominator for IMM-2.

6.What is the patient’s influenza vaccination status? (Influenza Vaccination Status)

_____1Influenza vaccine was given during this hospitalization.

_____2Influenza vaccine was received prior to admission during the current flu season, not during this hospitalization.

_____3Documentation of patient's or caregiver’s refusal of influenza vaccine.

_____4There was documentation of an allergy/sensitivity to influenza vaccine, anaphylactic latex allergy or anaphylactic allergy to eggs OR is not likely to be effective because of bone marrow transplant within the past 6 months OR history of Guillian-Barré syndrome within 6 weeks after a previous influenza vaccination.

_____5None of the above/Not documented/Unable to determine from medical record documentation.

_____6Only select this allowable value if there is documentation the vaccine has been ordered but has not yet been received by the hospital due to problems with vaccine production or distribution AND allowable values 1-5 are not selected.

a.If Influenza VaccinationStatus equals 1, 2, 3, or 4, the case will be included (Measure Category Assignment “E”). Stop abstracting. Add 1 to BOTH the numerator and denominator for IMM-2.

b.If the Influenza VaccinationStatus equals 5, the case will be included (Measure Category Assignment of “D”).Stop abstracting.Add 1 to the denominator for IMM-2. Add 0 to the numerator for IMM-2.

c.If Influenza VaccinationStatus equals 6, the case will be excluded (Measure Category Assignment of “B”).Stop abstracting.The case will not be included in the numerator or denominator for IMM-2.Add 0 to the numerator and denominator for IMM-2.

This material was prepared by the Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.HHSM-500-2013-13007I, FL-IQR-Ch8-02052015-05

CMS Abstraction Paper Tool – IMM-2Page 1 of 4

Discharges01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)