Good Samaritan Health Center
HF Worksheet Page 1 of 3
HF Core Measures Worksheet Medical Record Number: Billing Number: Patient Name: Discharge Date: Date of Birth: Measure Data Field Comments Yes/No Includes: comfort care, comfort measures, comfort measures only (CMO), end of life care, hospice care, palliative care, terminal care, V66.7 encounter for palliative care Excludes: chemical code only, do not cardiovert, do not defibrillate, do not intubate (DNI), do not resuscitate (DNR), keep comfortable, living will, no aggressive treatment, no antiarrhythmic therapy, no artificial respirations, no cardiac monitoring, No Cardiopulmonary Resuscitation (NCR), No chest compressions, No code, No CPR, No heroic or aggressive measures, No intubation and/or ventilation, No invasive procedures, No other protocols associated with advanced cardiac life support, No resuscitative medications, No resuscitative measures (NRM), No vasopressors, Supportive care Yes/No Y (Yes) Documentation in the medical record that the LVSF was assessed prior to arrival, during the hospital stay, or is planned for after discharge. N (No) No documentation that LVSF was assessed either prior to arrival or during this hospital stay nor a plan to assess LVSF after discharge, AND there is no reason documented by a physician/APN/PA for not assessing LVSF, or unable to determine from medical record documentation. R (R) Reason documented by physician/APN/PA for not assessing LVSF prior to arrival, during hospital stay, or planned after discharge.
Is there physician/APN/PA documentation of comfort measures only during the hospital stay?
Was the patient involved in a clinical trial during this hospital stay relevant to the measure set for this admission? Is there documentation of at least one of the following? Left ventricular systolic function (LVSF) assessment at anytime prior to arrival or during this hospitalization? A plan for LVSF assessment after discharge? A reason documented by a physician/APN/PA for not assessing LVSF? Is the LVSF documented as an ejection fraction (EF) less than 40% or as a description that is consistent with moderate or severe systolic dysfunction? Is the LVSF documented as an ejection fraction (EF) less than 40% or a narrative description consistent with moderate or severe systolic dysfunction?
Yes/No
Y LVSF is documented as an EF less than 40% or a narrative description consistent with moderate or severe systolic dysfunction. See Table 1.3. N (No) LVSF is not documented as an EF less than 40% or a narrative description not consistent with moderate or severe systolic dysfunction, or unable to determine from medical record documentation (e.g., LVSF assessment was never done, "Echo done last March" [without mention of LVSF results]). CONFIDENTIAL
Good Samaritan Health Center
HF Worksheet Page 2 of 3
Is BOTH a potential contraindication/reason for not prescribing ACEI at discharge AND a potential contraindication/reason for not prescribing ARB at discharge documented?
Y (Yes) Documentation that the patient has BOTH a potential contraindication/reason for not prescribing an ACEI at discharge AND a potential contraindication/reason for not prescribing an ARB at discharge, as evidenced by one or more of the following: ACEI allergy AND ARB allergy, Moderate or severe aortic stenosis (This is a contraindication to both ACEIs and ARBs.) Physician/APN/PA documentation of BOTH a reason for not prescribing ACEI at discharge AND a reason for not prescribing an ARB at discharge. ** Note: Documentation of a reason for not prescribing one class (either ACEI or ARB) should be considered implicit documentation of a reason for not prescribing the other class for the following five conditions only: Angioedema, Hyperkalemia, Hypotension, Renal artery stenosis, Worsening renal function/renal disease/dysfunction, Reason documented by physician/APN/PA for not prescribing an ARB at discharge AND an ACEI allergy, Reason documented by physician/APN/PA for not prescribing an ACEI at discharge AND an ARB allergy N (No) There is no documentation of BOTH a potential contraindication/reason for not prescribing an ACEI at discharge AND a potential contraindication/reason for not prescribing an ARB at discharge, or unable to determine from medical record documentation. Yes/No Yes/No
Was the patient prescribed an ACEI at discharge?: Was the patient prescribed an ARB at discharge?
CONFIDENTIAL
Good Samaritan Health Center
HF Worksheet Page 3 of 3
ACE Inhibitors: Accupril, Accuretic, Aceon, Altace, Benazepril, Benazepril Hydrochloride, Benazepril/amlodipine, Benazepril/hydrochlorothiazide,Capoten, Capozide, Capozide 25/15, Capozide 25/25, Capozide 50/15, Capozide 50/25, Captopril, Captopril HCT, Captopril/hydrochlorothiazide, Enalapril, Enalapril Maleate/diltiazem, Enalapril Maleate/hydrochlorothiazide, Enalapril/diltiazem, Enalapril/felodipine, Enalapril/hydrochlorothiazide, Enalaprilat, Fosinopril, Fosinopril Sodium/ hydrochlorothiazide, Lexxel, Lisinopril, Lisinopril/hydrochlorothiazide, Lotensin, Lotensin HCT, Lotrel, Mavik, Moexipril, Moexipril Hydrochloride, Moexipril, Hydrochloride/hydrochlorothiazide, Moexipril/hydrochlorothiazide, Monopril, Monopril HCT, Monopril HCT 10/12.5, Perindopril, Perindopril Erbumine, Prinivil, Prinzide, Quinapril, Quinapril HC1, Quinapril HC1/HCT, Quinapril Hydrochloride/hydrochlorothiazide,Quinapril/hydrochlorothiazide, Quinaretic, Ramipril, Tarka, Teczem, Trandolapril, Trandolapril/verapamil, Trandolapril/verapamil hydrochloride, Uniretic, Univasc, Vaseretic, Vasotec, Zestoretic, Zestril Angiotensin Receptor Blockers (ARBs) Atacand, Atacand HCT, Avalide, Avapro, Benicar, Benicar HCT, Candesartan, Candesartan/hydrochlorothiazide, Cozaar, Diovan, Diovan HCT, Eprosartan, Eprosartan/hydrochlorothiazide, Hyzaar, Irbesartan, Irbesartan/hydrochlorothiazide, Losartan, Losartan/hydrochlorothiazide, Micardis, Micardis HCT, Olmesartan, Olmesartan/hydrochlorothiazide, Tasosartan, Telmisartan, Telmisartan/hydrochlorothiazide, Teveten, Teveten HCT, Valsartan, Valsartan/hydrochlorothiazide, Verdia
Did the patient smoke cigarettes anytime during the year prior to hospital arrival?
Y (Yes) There is documentation that the adult patient smoked cigarettes anytime during the year prior to hospital arrival. Inclusion: + smoker, type of product not identified, + tobacco use, type of product not identified, History of smoking and documentation that the patient quit "several months ago" N (No) There is documentation that the adult patient did not smoke cigarettes anytime during the year prior to hospital arrival, smoking history was not addressed or unable to determine from medical record documentation. Yes/No Address Activity: Yes No Diet /Fluid Intake: Yes No Follow-Up Care: Yes No Discharge Medications: Yes No Symptoms Worsening: Yes No Weight Monitoring: Yes No
Was the patient given smoking cessation advice or counseling during this hospital stay? Please review the discharge instructions documented in the medical record and indicate whether the patient was consulted about the items listed to the right:
CONFIDENTIAL