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IN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 (CONTINUED)

21. VASCULAR ACCESS: What type of access was used on the last hemodialysis session on or between 10/1/2004 and

12/31/2004 at the patient’s primary in-center facility? Check only one of the following access types and follow the

corresponding directions.

AV Fistula

If patient had AV Fistula or Graft:

1. Was routine surveillance for the presence of stenosis performed between 10/1/04 and 12/31/04?

Graft

Yes

Unknown

2. If answer to question 1 is “Yes,” please check all methods of surveillance (below) that were

If you checked AV

utilized.

(See instructions on page 6).

Fistula or Graft, please

Color-Flow Doppler at least once between 10/1/04 and 12/31/04

answer questions 1

Static Venous Pressure at least once every 2 weeks between 10/1/04 and 12/31/04

and 2 at the right.

Dynamic Venous Pressure every HD session between 10/1/04 and 12/31/04

Dilution Technique at least once between 10/1/04 and 12/31/04

Other____________________________________

Catheter

If patient had a catheter or port access:

No fistula or graft surgically planned

1. Reason for catheter or port access:

Port Access

Fistula maturing, not ready to cannulate

(check all that apply)

(both arterial and venous limb)

Peripheral vascular disease

If you checked

Graft maturing, not ready to cannulate

Patient size too small for AV fistula or graft

Catheter or Port

(both arterial and venous limb)

Renal transplantation scheduled

Access, please

Temporary interruption of fistula due to

Patient preference

answer questions 1

clotting or revisions

Physician/Surgeon preference

and 2 at the right.

Temporary interruption of graft due to

Other__________________________

clotting or revisions

All fistula or graft sites have been exhausted

No fistula or graft surgically created at this time

2. Had a catheter or port access been used exclusively for the past 90 days or longer?

Yes

Unknown

22. Did the patient FIRST start hemodialysis during January 1, 2004-August 31, 2004

? DO NOT include

(see date #8 on page 1)

patients who transferred from peritoneal dialysis, had a newly failed transplant, or returned after an episode of

regained kidney function

Yes (answer 22A-B)

(See instructions on page 6).

A. What type of access was in use at the Initiation of a maintenance course of hemodialysis (First hemodialysis was during

JAN 1, 2004-AUG 31, 2004.)?

AV Fistula

Graft

Catheter

Port Access

Unknown

B. What type of access was in use 90 days later?

AV Fistula

Graft

Catheter

Port Access

Unknown

INSTRUCTIONS FOR COMPLETING QUESTIONS 18 THROUGH 22 (Continued from page 1): To answer questions 18

through 22, review the patient’s clinic or facility medical record for OCT 1, 2004 through DEC 31, 2004. Do not leave any

items blank. Enter NF/NP if the information cannot be located.

18A: Enter the patient’s 1st pre-dialysis hemoglobin (Hgb) for each month OCT, NOV, DEC 2004. Include the date the lab was

drawn. If not found or not performed during the month, enter NF/NP.

18B.1: Check the appropriate box to indicate if the patient had EPOETIN prescribed at anytime during the 28 days BEFORE the

date of the hemoglobin in 18A or had DARBEPOETIN (Aranesp

) prescribed at anytime during the 28 days BEFORE the date

of the hemoglobin value in 18A. If the answer is NO to both, skip to prescriber question 18C.

18.B.2: If Epoetin was prescribed, enter the PRESCRIBED Epoetin dose, not the administered dose, in units given at each

dialysis treatment during the 7 days immediately before the date of the hemoglobin value in 18A, even if the patient did not

receive the dose. This includes any prescribed dose not given because of an error or the patient missed a treatment, etc. Enter

“0” if the patient was on “Hold” for a treatment. (For the purposes of this collection, a “Hold” order will be considered a 0 unit

prescribed dose.) If Epoetin is prescribed less frequently than every dialysis treatment, leave the unit/tx space blank to

indicate one or two doses per the 7-day period.

If Darbepoetin (Aranesp

) was prescribed, enter the PRESCRIBED Darbepoetin dose, not the administered dose, in micrograms

per month during the 28 days immediately before the date of the hemoglobin value in 18A, even if the patient did not rereive the dose.

This includes any prescribed dose not given because of an error or the patient missed a treatment, etc. Enter”0” if the patient was on

“Hold”. (For the purposes of this collection, a “Hold” order will be considered a 0 mcg/month prescribed dose.)

18.B.3: Enter the number of times per week that Epoetin was prescribed (check the box if Epoetin was prescribed less than once

per week) OR the number of times per month Darbepoetin was prescribed.

CMS – 820 (Rev.1/27/05)

Form Cms-820 - In-Center Hemodialysis (Hd) Clinical Performance Measures Data Collection - 2005 Page 4

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