Log InRegister

Reporting And Data

Quality Indicators Results Form (rev. Oct. 2019)

  • MM slash DD slash YYYY
  • Numerator (# met):
  • Denominator (total #):
  • Percentage Met:
  • Numerator (# met):
  • Denominator (total #):
  • Percentage Met:
  • Numerator (# met):
  • Denominator (total #):
  • Percentage Met:
RMWG Target Percentage
92%

DEFINITION ( Numerator and Denominator )

Physician Compliance with Opioid Prescribing Requirements (AB 474)

  • (Numerator) all patients who are prescribed Schedule II, III, or IV drugs for pain in the ED
    • whose chart reflects
    • bona fide relationship with the patient; and
    • evaluation and risk assessment, including
      • review of PDMP and patient’s medical history
      • physical exam
      • obtain and review medical records, document the conclusions, and assess patient’s mental health and risk of abuse, dependency and addiction; and
    • preliminary diagnosis of the patient; tailored treatment plan, and
    • documented reasons for prescribing the controlled substance instead of alternative; and
    • obtain informed written consent from the patient, parent, or legal guardian

  • (Denominator) all patients who are prescribed Schedule II, III, or IV drugs for pain in the ED

Age Appropriate Vital Signs w/in 20 minutes of Discharge from ED

  • (Numerator) all patients who come to the ED for treatment
    • will have age-appropriate vital signs (e.g., TPR)
    • taken and charted
    • within 20 minutes of discharge from the ED
    • regardless of where patient goes (e.g., home, inpatient unit, transfer to another facility, etc.

  • (Denominator) all patients who come to the ED for treatment

Prompt communication of critical lab values to appropriate healthcare professional

  • (Numerator) number of successful prompt (within 1 hour) person-to-person communications of critical lab values (lab to healthcare professional who ordered test, or to appropriate alternative, e.g., healthcare professional with current responsibility for the patient’s care such as emergency room provider, admitting physician or hospitalist per hospital policy)

  • (Denominator) number of lab results with critical values

Sentinel Events Report sentinel events by sending a scanned or faxed copy of the SE that you reported to the State to Becky at NRHP (send sentinel event reports as they occur - we will discuss at quarterly meetings, but NRHP Staff need to be notified at same time event is reported)


Joint Commission Guidelines for Random Sampling:
Fewer than 30 charts     -  100%
30-100 charts                  - 30 cases
101-500 charts                - 50 cases
More than 500                - 70 cases

DISCLAIMER
Although many of these requirements apply to individual medical professionals and other types of hospitals and health care facilities, the information is presented solely to support Critical Access Hospitals. The reporting requirements and legal mandates on this site are not an exhaustive list and Nevada Rural Hospital Partners, Inc. bears no responsibility or liability for any hospitals' or providers' failure to comply with Federal or State laws or regulations.