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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