Download PINNACLE DCF v1.4 - American College of Cardiology

NCDR® PINNACLE Registry® v1.4.1 (CardioEncounters)
Data Collection Form
Practice Innovation and Clinical Excellence
MRN1500:
Encounter Date1510:
Provider NPI1550:
Encounter TIN1555:
mm / dd / yyyy Practice ID1520:
Location ID1530:
Patient new to the Practice1560: O No
O Yes
A. PATIENT DEMOGRAPHICS
Patient Name(Last, First, MI)2000, 2010, 2020:
Date of Birth2050:
Race:
(Check all that apply)
SSN2030:
Sex2060:
mm / dd / yyyy
O Male
PatientID2040:
□ Patient Deceased2065
O Female
Patient Zip2200:
(auto)
à Date2067 mm / dd / yyyy
□ White2070
□ Black/African American2071
□ American Indian/Alaskan Native2073
2072
2080
2081
□ Asian à If Yes, □ Asian Indian
□ Chinese
□ Filipino2082 □ Japanese2083 □ Korean2084 □ Vietnamese2085 □ Other2086
□ Native Hawaiian/Pacific Islander2074 à If Yes, □ Native Hawaiian2090 □ Guamanian or Chamorro2091 □ Samoan2092 □ Other Island2093
Hispanic or Latino Ethnicity2076: O No
O Yes
à If Yes, Ethnicity Type: (Check all that apply)
□ Mexican, Mexican-American, Chicano2100
□ Puerto Rican2101
□ Cuban2102
□ Other Hispanic, Latino or Spanish Origin2103
Insurance Payers: (Check all that apply)
□ Medicaid (fee for service)3030
3020
□ Private Health Insurance
□ Medicaid (managed care)3031
□ Military Health Care3023 □ State Specific Plan (non-Medicaid)3024 □ Indian Health Service3025
□ Medicare (fee for service)3028
□ Medicare (managed care)3029
□ Non-US Insurance3026
□ None3027
Payer ID3100: ______ ______ ______ ______ ______
B. DIAGNOSES/CONDITIONS/CO-MORBIDITIES (CHECK ALL THAT APPLY)
□ Coronary Artery Disease4000
□ Atrial Fibrillation/Flutter4010
□ Dyslipidemia4020
□ Diabetes Mellitus (Any)4150
□ Hypertension4030
□ Peripheral Arterial Disease4090
□ PAD – Acute Limb Ischemia4100
□ PAD – Claudication4110
□ PAD – Critical Limb Ischemia4120
□ PAD – Foot/Leg cellulitis4130
NOTE: INDICATE IF THE PATIENT HAS A HISTORY OF ANY OF THE FOLLOWING.
àDate4002 mm / dd / yyyy
□ PAD – Lower Extremity Osteomyeleitis
àDate4012 mm / dd / yyyy
(with or without limb ischemia)
4140
àDate4142 mm / dd / yyyy
àDate4082 mm / dd / yyyy
□ Unstable Angina4080
àDate4042 mm / dd / yyyy
mm / dd / yyyy □ Heart Failure4040
à If Yes, □ New diagnosis4050(within 12 months)
mm / dd / yyyy
àDate4022 mm / dd / yyyy
àDate4152
àDate4032
àDate4062 mm / dd / yyyy
□ Stable Angina4060
mm / dd / yyyy
à If Yes, □ New diagnosis4070 (within 12 months)
àDate4222 mm / dd / yyyy
mm / dd / yyyy □ Ischemic Vascular Disease4220
àDate4232 mm / dd / yyyy
mm / dd / yyyy □ Peripheral Vascular Disease4230
àDate4092 mm / dd / yyyy
àDate4102
àDate4112
àDate4122
àDate4132 mm / dd / yyyy
□ Chronic Kidney Disease4240
□ Chronic Liver Disease4250
C. CARDIAC EVENTS
àDate4242 mm / dd / yyyy
àDate4252 mm / dd / yyyy
NOTE: INDICATE IF THE PATIENT HAS A HISTORY OF ANY OF THE FOLLOWING.
SPECIFY ALL EVENT(S) AND IF AVAILABLE, EVENT DATE(S) THAT OCCURRED.
EVENT5135
Myocardial InfarctionE001
PCI (Any)
E029
EVENT DATE(S)5136
mm / dd / yyyy
mm / dd / yyyy
EVENT5135
EVENT DATE(S)5136
Non Intracranial Major Hemorrhage
Location – Intra-ocularE010
mm / dd / yyyy
Non Intracranial Major Hemorrhage
Location – Intra-spinalE011
mm / dd / yyyy
Non Intracranial Major Hemorrhage
Location – PericardialE012
mm / dd / yyyy
PCI – Bare Metal Stent ImplantE002
mm / dd / yyyy
PCI – Drug Eluting Stent ImplantE003
mm / dd / yyyy
PCI – Other (non-stent) InterventionE004
mm / dd / yyyy
Systemic EmbolismE005
mm / dd / yyyy
Non Intracranial Major Hemorrhage
Location – Retroperitoneal/AbdominalE013
mm / dd / yyyy
Hemorrhage (Any)E031
mm / dd / yyyy
TIAE014
mm / dd / yyyy
E006
E030
Minor Hemorrhage
mm / dd / yyyy
Stroke (Any)
Intracranial HemorrhageE007
mm / dd / yyyy
Stroke – IschemicE015
Non Intracranial Major Hemorrhage
(Any)E032
Non Intracranial Major Hemorrhage
Location – Intra-articular (Atraumatic)E009
© 2010 American College of Cardiology Foundation
mm / dd / yyyy
Stroke – Hemorrhagic
mm / dd / yyyy
mm / dd / yyyy
E016
mm / dd / yyyy
mm / dd / yyyy
28-Sep-2015
Page 1 of 5
MRN:
Encounter Date:
Practice ID:
mm / dd / yyyy
C. CARDIAC EVENTS (CONT.)
Location ID:
NOTE: INDICATE IF THE PATIENT HAS A HISTORY OF ANY OF THE FOLLOWING.
SPECIFY ALL EVENT(S) AND IF AVAILABLE, EVENT DATE(S) THAT OCCURRED.
EVENT5135
EVENT DATE(S)5136
Coronary Artery Bypass GraftE017
Cardiac Valve Surgery
E018
mm / dd / yyyy
Heart Transplantation
Cardiac Therapeutic Procedure
E022
E024
Carotid Artery Stent
E026
Permanent Pacemaker
Carotid Artery Stent – Left
PAD – Peripheral Bypass
mm / dd / yyyy
E043
mm / dd / yyyy
PAD – Peripheral Intervention
E044
mm / dd / yyyy
Syncope
NOTE: COMPLETE ONLY IF ASSESSED DURING TODAY’S ENCOUNTER. IF NOT ASSESSED, LEAVE BLANK.
Blood Pressure6010, 6011: _______ / _______ mmHg
Height: _____________ O in6000 O cm6001
□
Weight: _____________ O lbs6020 O kg6021
Heart Rate6015: __________ bpm
Patient unable to be weighed6025
O Never
O Current
O Quit within past 12 months
O Screening not performed for medical reasons
O Quit more than 12 months ago
□ Cigarettes6035 □ Cigars6036 □ Pipe6037 □ Smokeless6038
à If Current or Quit within 12 months, Tobacco Type: (check all that apply)
à If Current or Quit within 12 months, Smoking Cessation Counseling Provided6040:
O No
O Yes
Patient asked, during any previous encounter in the past 24 months, about the use of Tobacco6045: O No
Alcohol Use
6047
:
O None
O <1 drinks/wk
O 2-7 drinks/wk
O 8-14 drinks/wk
Advance Care Plan OR Discussion of Advance Care Plan Documented6050: O No – Not documented
CAD
ANGINA SYMPTOMS AND ACTIVITY ASSESSMENT(S)
CCS Class6430:
O No angina
OI
O II
O III
□ Seattle Angina Questionnaire Completed
O IV
HF
NYHA Class
: OI
O II
O III
HF
O >= 15 drinks/wk
O No – patient reason
O Yes
NOTE: COMPLETE AT LEAST ONE TO MEET MEASURE.
□ Other Tool/Method
to Assess Angina Symptoms and Activity
6440
NOTE: COMPLETE AT LEAST ONE TO MEET MEASURE.
O IV
□ Kansas City Cardiomyopathy Questionnaire Completed6135 □ Chronic Heart Failure Questionnaire from Guyatt Completed6145
□ Minnesota Living with HF Questionnaire Completed6150
□ Other Tool/Method to Assess Heart Failure Activity Completed6155
HEART FAILURE SYMPTOMS ASSESSMENT(S)
Dyspnea Present6200: O No
O Yes
Orthopnea Present6210:
O No
Rales Present6220:
Ascites Present
O No
O Yes
: O No
O Yes
6250
Peripheral Edema Present6230: O No
O Yes
O No
O Yes
Hepatomegaly Present
Jugular Venous Distention Present6275: O No
© 2010 American College of Cardiology Foundation
6260
:
NOTE: COMPLETE AT LEAST ONE TO MEET MEASURE.
O Yes
HEART FAILURE PHYSICAL ASSESSMENT(S)
HF
O Yes
Completed
6435
HEART FAILURE ACTIVITY ASSESSMENT(S)
6130
mm / dd / yyyy
E065
mm / dd / yyyy
D. ENCOUNTER INFORMATION
Tobacco Use6030 :
mm / dd / yyyy
E038
mm / dd / yyyy
E027
mm / dd / yyyy
Carotid Artery Stent – Right
mm / dd / yyyy
ICD Implant
mm / dd / yyyy
E036
(Any)
E037
mm / dd / yyyy
E025
PTCA
Carotid Endarterectomy – Left
mm / dd / yyyy
CRT
mm / dd / yyyy
E035
mm / dd / yyyy
E023
mm / dd / yyyy
Carotid Endarterectomy – Right
mm / dd / yyyy
Cardioversion
mm / dd / yyyy
E033
E034
mm / dd / yyyy
E021
CRT-D
Carotid Endarterectomy (Any)
mm / dd / yyyy
E020
EVENT DATE(S)5136
Vascular ComplicationE028 (requiring intervention)
mm / dd / yyyy
E019
LVAD
EVENT5135
NOTE: COMPLETE AT LEAST ONE TO MEET MEASURE.
S3 Gallop Present6240:
S4 Gallop Present
6270
:
O No
O Yes
O No
O Yes
O Yes
28-Sep-2015
Page 2 of 5
MRN:
mm / dd / yyyy
Encounter Date:
Practice ID:
Location ID:
BMI
PLAN OF CARE
□ Body Mass Index Screen Performed6900
O Yes – Referral/Plan Documented
O No Qualifying Event/Diagnosis
O Patient Already Participating in Rehab
CAD
Cardiac Rehabilitation Referral or Plan for Qualifying
Event/Diagnosis in past 12 months6450:
O No Referral/Plan – Medical Reason
O No Referral/Plan – System Reason
(Note: Cardiac event/diagnoses includes Myocardial Infarction, Valve surgery, Heart Transplant, CABG, PCI or new Stable Angina diagnosis.)
Referral for Consideration for Coronary Revascularization6460:
Referral for Additional Evaluation/Treatment of Anginal Symptoms
6470
:
Discussion of Lifestyle Modifications Documented6100:
6400
CAD/HF
□ BMI Management Plan6910
àDate6902 mm / dd / yyyy
LVEF Assessed Date
:
O No
O Yes
O No
O Yes
O No
O Yes
mm / dd / yyyy
LVEF6410: _______ %
LV Qualitative Assessment6420:
(Note: If a LVEF range is documented, take the average, round up and refer to the
LVEF Status ranges (right) to code.)
O Hyperdynamic: > 70
O Mildly reduced: 40 – 49
O Severely reduced: ≤ 29
O Normal: 50 – 70
O Moderately reduced: 30 – 39
HF
HF Education Completed/Documented: (Check all that apply)
□ All of the following6280 □ Weight Monitoring6281 □ Diet (Sodium Restriction)6282 □ Symptom Management6283
□ Physical Activity6284 □ Smoking Cessation6285 □ Medication Instruction6286
□ Prognosis/end-of-life Issues6287
6288
□ Minimizing or Avoiding use of NSAIDs
□ Referral for visiting nurse or specific educational or management programs6289
ICD Counseling6300:
O Yes – Patient Counseled
HF Plan of Care6310:
O No
O No – Patient Not Counseled
O No Counseling – Medical Reason
O Yes
ATRIAL FIBRILLATION/FLUTTER ASSESSMENT AND TREATMENT
AFib/Flutter Duration6500:
AFib/Flutter Type
6510
:
O First diagnosed
O Paroxysmal
O Non-Valvular
O Valvular
O Persistent
O Long-standing Persistent
O Permanent
INR Value6530: __________
àDate6532 mm / dd / yyyy Atrial Fibrillation Symptom Frequency6570: (every) ______ days
□ EP Study6540
□ Atrial Ablation6550
àDate6542 mm / dd / yyyy
□ Atrial Fibrillation Recurrence6560
àDate6562 mm / dd / yyyy
CHADS2 Score6600: __________
E. LABORATORY RESULTS
7010
CAD
□ Rate Control Therapy6590
CHA2DS2-VASc Score6610: __________
□ Rhythm Control Therapy6595
HAS-BLED Score6620: __________
NOTE: ENTER MOST RECENT LAB RESULTS AND/OR INDICATE THE LABS ORDERED DURING THIS ENCOUNTER.
Lipid Panel Obtained Date7000:
Total Cholesterol
Atrial Fibrillation Symptom Duration6580:
àDate6552 mm / dd / yyyy O < 48 hours O >= 48 hours – 7 days O >7 days – 3 months O > 3 months
:
___________ mg/dL
High Density Lipoprotein (HDL)7020: ___________ mg/dL
Low Density Lipoprotein (LDL)7030:
Glucose timing7060:
mm / dd / yyyy
___________ mg/dL
Diabetes
TE RISK
FACTORS
AFIB
□ Afib/Flutter Etiology – Transient/Reversible Cause6520 (e.g., pneumonia, hyperthyroidism, pregnancy, post-surgery)
O Fasting
O Random
Plasma Glucose
Results7070:
_________ mg/dL
àDate7072 mm / dd / yyyy
HbA1c7080:
___________ %
àDate7082 mm / dd / yyyy
Direct Low Density Lipoprotein (DLDL)7040: _______ mg/dL
HF
Triglycerides7050:
___________ mg/dL
□ Initial Labs ordered for newly diagnosed Heart Failure (within past 12 months) or patient new to the practice7100
RENAL
(Note: Initial labs for HF include Serum Electrolytes (including Ca+ and Mg+), CBC, U/A, TSH, Liver Function tests, BUN, Creatinine and Glucose.)
Estimated Glomerular Filtration Rate7200: ___________ mL/min
àDate7202 mm / dd / yyyy
Creatinine Clearance7220:
________
àDate7222 mm / dd / yyyy
Serum Creatinine7230:
________ mg/dL
àDate7232 mm / dd / yyyy
© 2010 American College of Cardiology Foundation
28-Sep-2015
Page 3 of 5
MRN:
Encounter Date:
mm / dd / yyyy
Practice ID:
F. MEDICATIONS
9300
MEDICATION
* DENOTES THAT THE MEDICATION(S) ARE
REQUIRED FOR SPECIFIC PERFORMANCE
MEASURES OR
PQRS MEASURES.
DOSE
STRENGTH9301
ANTIARRYTHMIC
ANTICOAGULANTS*
MEASURE9302
(E.G. MG, ML)
ADMINISTERED9305
DOSING
FREQUENCY9303
YES
(PRESCRIBED)
NO
(MEDICAL REASON)
NO
NO
(PATIENT REASON) (SYSTEM REASON)
O
O
O
O
Ranolazine
O
O
O
O
Ivabradine
O
O
O
O
Antiarrhythmic (Any)
O
O
O
O
Amiodarone
O
O
O
O
Dronedarone
O
O
O
O
Apixaban
O
O
O
O
Dabigatran
O
O
O
O
Rivaroxaban
O
O
O
O
Warfarin
O
O
O
O
Edoxaban+
O
O
O
O
ACE Inhibitor*
O
O
O
O
ARB*
O
O
O
O
Combination Antihypertensive
O
O
O
O
Sacubitril/Valsartan (Entresto)
O
O
O
O
Medoxomil/Amlodipine/
Hydrochlorothiazide (Tribenzor)
O
O
O
O
Calcium Channel Blocker
O
O
O
O
Dihydropyridine
O
O
O
O
Non-Dihydropyridine
O
O
O
O
Diuretic (Any)
O
O
O
O
Loop Diuretic
O
O
O
O
Thiazide Diuretic
O
O
O
O
Potassium Sparing Diuretic
O
O
O
O
Clopidogrel
O
O
O
O
Ticlopidine
O
O
O
O
Prasugrel
O
O
O
O
Ticagrelor
O
O
O
O
Aspirin
O
O
O
O
Aspirin-dipyridamole (Aggrenox)
O
O
O
O
Beta Blocker (Any)
O
O
O
O
Atenolol
O
O
O
O
Metoprolol
O
O
O
O
Nebivolol
O
O
O
O
Bisoprolol
O
O
O
O
Carvedilol
O
O
O
O
Sustained release metoprolol
succinate
O
O
O
O
P2Y12
DIURETICS*
ANTIHYPERTENSIVE
ANTIPLATELETS
DOSING
Nitroglycerin
CA CHANNEL
BLOCKERS
ANTIANGINAL
+ INDICATES A MEDICATION IS NOT YET BEEN
APPROVED.
BETA BLOCKER
Location ID:
PLEASE LEAVE BLANK IF THERE IS NO CLINICAL INDICATION FOR A MEDICATION TO BE PRESCRIBED, OR IF NO DOCUMENTATION
EXISTS AS TO IF A MEDICATION WAS PRESCRIBED/CONTINUED.
© 2010 American College of Cardiology Foundation
28-Sep-2015
Page 4 of 5
MRN:
mm / dd / yyyy
Encounter Date:
Practice ID:
Location ID:
PLEASE LEAVE BLANK IF THERE IS NO CLINICAL INDICATION FOR A MEDICATION TO BE PRESCRIBED, OR IF NO DOCUMENTATION
EXISTS AS TO IF A MEDICATION WAS PRESCRIBED/CONTINUED.
F. MEDICATIONS
9300
MEDICATION
* DENOTES THAT THE MEDICATION(S) ARE
DOSE
STRENGTH9301
REQUIRED FOR SPECIFIC PERFORMANCE
MEASURES OR
PQRS MEASURES.
+ INDICATES A MEDICATION IS NOT YET
DOSING
MEASURE9302
(E.G. MG, ML)
ADMINISTERED9305
DOSING
FREQUENCY9303
YES
(PRESCRIBED)
NO
NO
NO
(MEDICAL REASON) (PATIENT REASON) (SYSTEM REASON)
O
O
O
O
Metformin
O
O
O
O
Pioglitazone
O
O
O
O
Rosiglitazone
O
O
O
O
Lipid Lowering Non-Statin
O
O
O
O
Lipid Lowering Statin (Any)
O
O
O
O
Atorvastatin
O
O
O
O
Rosuvastatin
O
O
O
O
Simvastatin
O
O
O
O
Low Intensity Statin
O
O
O
O
Moderate Intensity Statin
O
O
O
O
High Intensity Statin
O
O
O
O
Alirocumab
O
O
O
O
Bupropion
O
O
O
O
Nicotine Replacement Therapy
O
O
O
O
Varenicline
O
O
O
O
Corticosteroids
O
O
O
O
Digoxin (Any)
O
O
O
O
NSAID
O
O
O
O
Proton Pump Inhibitor
O
O
O
O
SSRI
O
O
O
O
STATIN
Insulin
SMOKING
OTHER
CESSATION
PCKSK9
LIPID LOWERING
GLUCOSE-LOWERING
BEEN APPROVED
Evolocumab
G. HOSPITALIZATIONS
Hospital Admission Date9500: mm / dd / yyyy à If Admitted, Primary Reason9505: ________ Coding Standard9510: O ICD-9 O ICD-10
Discharge Date9502:
mm / dd / yyyy
© 2010 American College of Cardiology Foundation
Secondary Diagnosis9507: ________
28-Sep-2015
Page 5 of 5